Every finding on record at Worth County Public Health

A Recertification Survey was conducted by the Iowa Department of Inspections, Appeals & Licensing from 7/29/24 through 7/31/24 the home health agency was found to be operating in compliance with the requirements of the Establishment of Emergency Preparedness.

The Iowa Department of Inspections, Appeals & Licensing conducted a Recertification Survey from 7/29/24 through 7/31/24. The recertification survey identified the home health agency was operating out of compliance with the following standard level home health regulations. The agency reported a current census of 33 patients at the time of the survey.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on interviews, clinical record reviews, and policy review, the agency failed to complete a Drug Regimen Review (DRR) with all required components for 6 of 6 sampled patients requiring DRRs (Patients #1, #2, #3, #4, #6 and #7). Failure to perform a complete DRR, increased the risk for patients to experience potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Findings include: 5. Patient #3 had an admission date of 11/7/19. Review of the clinical record revealed the following: a. The POC, dated 6/12/24 to 8/10/24, included orders for skilled nursing services and orders for medications. b. The comprehensive assessment, dated 6/21/24, identified the potential drug interactions and the duplicate therapies. The comprehensive assessment failed to identify if the medication regimen was effective for the patient, if patient was compliant with all medications, and if there were any medications requiring laboratory monitoring. The agency failed to address all 5 components of the DRR. 6. Patient #7 had a start of care date of 5/2/24. a. The Plan of Care (POC), dated 5/2/2024 to 6/30/2024, included orders for skilled nursing services and orders for medications. b. The comprehensive assessment, dated 5/2/24, identified the potential drug interactions and duplicate therapies. The comprehensive assessment failed to identify if the medication regimen was effective for the patient, if patient was compliant with all medications, and if there were any medications requiring laboratory monitoring. The agency failed to address all 5 components of the DRR. The above findings were reviewed with the agency Administrator and Clinical Manager. According to the agency policy titled Medication Profile, dated 12/2022, the Registered Nurse will complete a Drug Regiment Review (DRR) for each client at the time of admission and when a comprehensive assessment is due. The DRR is to identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, and contraindicated medications. During an interview on 7/29/24 at 3:02 PM with Staff B, Clinical Manager, a complete DRR is done on admission, when a medication change occurs, at every recertification, resumption of care, transfer and discharge. The completed DRR is sent to the provider within 24 for hours to review. 1.Patient #1 had an admission date of 1/25/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/18/24 to 9/15/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 7/15/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR. 2.Patient #2 had an admission date of 4/16/24. Review of the clinical record revealed the following: a. The POC, dated 6/15/24 to 8/13/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 6/10/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR. 3.Patient #4 had an admission date of 11/23/22. Review of the clinical record revealed the following: a. The POC, dated 7/15/24 to 9/13/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 7/12/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR. 4. Patient #6 had an admission date of 5/16/24. Review of the clinical record revealed the following: a. The POC, dated 5/16/24 to 7/14/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 5/16/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on observations, interviews, record review, and policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient for 2 of 3 home visit observations (Patients #2 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medication and /or treatments according to the assessed needs and physician orders. Findings include: 2.Patient #2 had a start of care date of 4/16/24. Clinical record review, home visit observation, and accompanying interviews revealed the following: a. The POCs, dated 4/16/24 to 6/14/24 and 6/15/24 to 8/13/24, included the following durable medical equipment (DME) used by the patient: compression stockings, grab bars/safety rails, long handled sponge, hand-held shower, oral medication tray, shower chair, cane, incentive spirometer, chair pedal exerciser, and 4 wheeled walker with seat. b. During a home visit observation on 7/30/24 with Staff C, RN, the surveyor observed a life alert button sitting on the table. An interview with Patient #2 during this same visit revealed the patient has had the life alert button for approximately one year and wears it daily. The POC failed to identify the DME life alert button. The above findings were reviewed with the Administrator and Clinical Manager. Findings include: According to agency policy, Plan of Care, dated October 2023, the Plan of Care shall be completed in full to include all pertinent diagnoses, medication and treatments, and supplies and equipment required. 1. Patient #3 had a start of care date of 11/7/2019. Clinical record review, home visit observation, and accompanying interviews revealed the following: a. The Plan of Care (POC) dated, 6/12/2024 to 8/10/2024, identified the patient used the following equipment: Adult Diapers; Oral medication tray; Hand-held shower; Grab bars/safety rails; Glasses, electric razor, and upper dentures. b. During a home observation visit on 7/30/24 at 11:30 AM, Staff B, Registered Nurse (RN), educated the patient on the importance of using the patient's walker when moving about through the house. Staff B noted to surveyor the walker was usually by his recliner chair within reach, but was not there during the home observation visit. c. Patient had been hospitalized from 6/19/24 through 6/21/24, related to symptoms of a cardiovascular accident, (stroke). Discharge instructions dated 6/21/24, included instructions to use a walker upon return to the home. d. The POC was not updated to include a walker as part of the medical supplies utilized by the patient. The POC failed to include all of the medical equipment utilized by the patient.

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 observations, interviews, record review and policy review, the agency failed to maintain the Plan of Care for patients and to update the Plan of Care with any new verbal/interim physician orders for 1 of 2 sampled patients with new orders following a resumption of care (Patient #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to the assessed needs and physician orders. Findings Include: According to the agency policy titled Plan of Care, dated October 2023, the Plan of Care shall be completed in full to include all pertinent diagnoses, medications and treatments, and all verbal orders obtained from the clients physician for changes in the Plan of Care. 1. Patient #3 had a start of care date of 11/7/2019. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/12/24 to 8/10/24, included orders for regular diet. b. Patient was hospitalized from 6/19/24 to 6/21/24 for symptoms of cerebrovascular accident (stroke). c. Patient had a resumption of care completed on 6/21/24 with hospital discharge instructions to change from a regular diet to a mechanical soft diet with the addition of Ensure (nutritional supplement) three times per day. The agency failed to record all orders in the plan of care. The above findings were reviewed with the agency Administrator and the Clinical Manager.

The recertification survey, conducted from 7/19/21 through 7/22/21, identified the following standard level deficiencies related to emergency preparedness.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on clinical record review, agency staff interview and agency policy review, the home health agency failed to ensure the clinical record included completion of an individualized emergency preparedness plan or review of the patient's individualized emergency plan as part of the comprehensive assessment for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #8 and #10) with a record review which included a comprehensive assessment completed since 9/19/18. The agency reported a current census of 43 patients at the time of the survey. Failure to ensure the agency maintained a copy of the patient's individualized emergency plans developed as part of the comprehensive assessment placed patients at risk for staff being unaware and unprepared to respond in a timely and effective manner to potential health and safety hazards the patient may encounter. Findings include: According to the agency's policy titled, Home Health Emergency Preparedness Plan, Policies, and Procedures, dated 10/31/17, patients will receive Emergency Preparedness Plan education with a handout at admission or at their next comprehensive assessment. The nurse will fill out an Emergency Reference Information form that the patient will sign. The patient will keep a copy, the agency will keep a copy in the patient's record, and a copy will be given to the administrator. On 7/21/21 at 2:24 PM, interview with agency Administrator revealed the individualized emergency plan is given to patients on admission with information regarding emergency preparedness and the form is filled out and kept in the patient's home. The nurses update the form if any changes occur. The agency has a sheet to determine patient's acuity level for the form used. 1. Patient #1 had a start of care date of 2/18/21. Clinical record review revealed: a. The Emergency Reference Information form, dated and signed by the patient as completed on 2/18/21. b. The initial skilled nursing visit note, completed with the comprehensive assessment and dated 2/18/21, included documentation the emergency plan was explained to the patient and signed. c. The updates to the comprehensive assessments for recertification, dated 4/14/21 and 6/15/21, lacked documentation the nurse reviewed an individualized emergency preparedness plan with the patient. 2. Patient #2 had a start of care date of 3/17/21. Clinical record review revealed: a. The Emergency Reference Information form, dated and signed by the patient as completed on 3/17/21. b. The initial skilled nursing visit note, completed with the comprehensive assessment and dated 3/17/21, included documentation the emergency plan was explained to the patient and signed. c. The updates to the comprehensive assessments for recertification and skilled nursing visit notes, dated 5/12/21 and 7/14/21, lacked documentation the nurse reviewed an individualized emergency preparedness plan with the patient. 3. Patient #4 had a start of care date of 5/24/19. Clinical record review revealed: a. The Emergency Reference Information form, dated and signed by the patient as completed on 5/24/19. b. The initial skilled nursing visit note, completed with the comprehensive assessment and dated 5/24/19, included documentation the emergency plan was explained to the patient and signed. c. The updates to the comprehensive assessments for recertification and skilled nursing visit notes, dated 3/10/21, 5/12/21, and 7/7/21, lacked documentation the nurse reviewed an individualized emergency preparedness plan with the patient. d. The update to the comprehensive assessment for resumption of care and skilled nursing visit note, dated 4/7/21, lacked documentation the nurse reviewed an individualized emergency preparedness plan with the patient. 4. Patient #10 had a start of care date of 10/12/2020 and a discharge date of 3/29/21. Clinical record review revealed: a. The Emergency Reference Information form, dated and signed by the patient as completed on 10/12/2020. b. The initial skilled nursing visit note, completed with the comprehensive assessment and dated 10/12/2020, included documentation the emergency plan was explained to the patient and signed. c. The updates to the comprehensive assessments for recertification and skilled nursing visit notes, dated 12/7/2020 and 2/8/21, lacked documentation the nurse reviewed an individualized emergency preparedness plan with the patient. d. The update to the comprehensive assessment for discharge from agency and skilled nursing visit note, dated 3/29/21, lacked documentation the nurse reviewed an individualized emergency preparedness plan with the patient. 5. Patient #3 had a start of care date of 5/20/2021. Clinical record review revealed the following: The patient's clinical record included a copy of an emergency preparedness plan, completed following admission to home health services. a. The update to the comprehensive assessment at the time of resumption of care, dated 6/28/2021, lacked documentation of a safety reassessment to determine the individualized needs of the patient during a disaster or emergency. b. The update to the comprehensive assessment at the time of recertification, dated 7/14/2021, lacked documentation of a safety reassessment to determine the individualized needs of the patient during a disaster or emergency. 6. Patient #5 had a start of care date of 10/8/2020. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission, dated 10/8/2020, lacked documentation of a safety assessment to determine the individualized needs of the patient during a disaster or emergency. b. The update to the comprehensive assessment at the time of recertification, dated 12/3/2020, lacked documentation of a safety assessment to determine the individualized needs of the patient during a disaster or emergency. c. The clinical record lacked documentation of any further updates to the comprehensive assessment, therefore, the agency failed to continue to reassess for individualized needs of the patient during a disaster or emergency. d. The clinical record lacked documentation of a completed emergency preparedness plan for Patient #5. The patient continued to receive services from the home health agency at the time of the survey. 7. Patient #6 had a start of care date of 10/31/2016. Clinical record review revealed the following: a. The emergency preparedness regulations were not in effect until November 2018. The clinical record lacked documentation of any updates to the comprehensive assessment, therefore, the agency failed to initially assess and continue to reassess for individualized needs of the patient during a disaster or emergency. b. The clinical record lacked documentation of a completed emergency preparedness plan of Patient #6. The patient continued to receive services from the home health agency at the time of the survey. 8. Patient #8 had a start of care date of 6/8/2021 and was discharged from agency services on 7/6/2021. Clinical record review revealed the following: a. The initial comprehensive assessment at the time of admission, dated 6/8/2021, lacked documentation of a safety assessment to determine the individualized needs of the patient during a disaster or emergency. b. The clinical record lacked documentation of an update to the comprehensive assessment at the time of discharge, therefore, the agency failed to reassess for individualized needs of the patient during a disaster or emergency. c. The clinical record lacked documentation of a completed emergency preparedness plan of Patient #8. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals in conjunction with with a recertification survey from 7/19/21 through 7/22/21 . The survey found the agency operating in substantial compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for infection control related to COVID-19. The recertification survey found the agency operating out of compliance with the following Conditions of Participation: 1. Condition of Participation 42 CFR 484.55 Comprehensive Assessment of Patients (G510, G546 and G550); and 2. Condition of Participation 42 CFR 484.60 Care Planning, Coordination and Quality of Care (G570, G572, G574, G580, and G590) The survey also found the agency operating out of compliance with multiple other standard level regulatory requirements. As a result of the agency's noncompliance with the Medicare Conditions of Participation for home health agencies, the home health agency, its registered nurses are prohibited from providing basic skills competency training, and prohibited from providing evaluation of home health aide written basic skills testing and evaluation of demonstrated competency of the hands on basic skills for the agency's home health aides for 2 years, beginning on 7/22/21 and ending on 7/22/23. The recertification survey found the agency operating out of compliance with the following regulatory requirements.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient/caregiver interview and agency staff interview, the agency: 1) failed to update the comprehensive assessment the last 5 days of every 60 days beginning with the start of care date (G546); 2) failed to failed to update the comprehensive assessment within 48 hours of the patient's return home from a hospital admission of 24 hours or more for any reason or on the resumption of care date (G548); 3) failed to failed to update the comprehensive assessment at discharge (G550) The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 43 patients.

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure accurate completion of all required components of the recertification comprehensive assessments with accompanying drug regimen review between day 56 and 60 of each 60 day certification period for 3 of 9 sampled patients requiring an update to the comprehensive assessment at the time of recertification (Patients #5, #6 and #7). The agency reported a census of 43 patients at the time of the survey. Failure to accurately and thoroughly complete recertification comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Home Care Aide Services and dated 10/2003, patients admitted to the personal care only program with no skilled service provision must have a comprehensive assessment with accompanying drug regimen review every 60 days. According to the agency policy, titled Office Visits Clients and dated 10/2003, the agency will provide office visits to patients who wish to be seen in the office and have a skilled nursing need. An evaluation will be made assessing the patient's living situation/condition, health status, cardiovascular status, respiratory status, elimination status, eyes/hearing, nutritional status, pain status, integument, musculoskeletal status, mental health, activities of daily living, social network and activities. The agency will also assess the patient's medications as part of the drug regimen review. The policy lacked any identification of how often the above stated assessments should be performed. According to the agency policy, titled Policies and Procedures using OASIS and dated 10/2003, each patient who meets the admission policies will receive a patient-specific comprehensive assessment that accurately reflects the patient's current health status, progress toward achievement of desired outcomes, continuing need for home care, medical/nursing/rehabilitative/social and discharge planning needs. The comprehensive assessment will be collected initially and then updated/revised at least every 60 days in the last five days of the plan of care (days 56-60). The comprehensive assessment will include a review of all of the medications the patient currently used (drug regimen review). 1. Patient #5 had a start of care date of 10/8/2020 and paid privately for agency services, receiving skilled nurse visits in the home health office. Clinical record revealed the following: a. The Plans of Care, dated 10/8/2020 to 12/6/2020, 12/7/2020 to 2/4/2021, 2/5/2021 to 4/5/2021, 4/6/2021 to 6/4/2021 and 6/5/2021 to 8/3/2021, included physician orders for skilled nursing services to perform administration of medication injections. b. The patient's clinical record lacked documentation of any updates to the comprehensive assessment except for an assessment of the patient's medications (drug regimen review) after 12/3/2020. 2. Patient #6 had a start of care date of 10/31/2016 and paid privately for agency services, receiving skilled nurse visits in the home health office. Clinical record revealed the following: a. The Plans of Care, dated 10/16/2020 to 12/14/2020, 12/15/2020 to 2/12/2021, 2/13/2021 to 4/13/2021, 4/14/2021 to 6/12/2021 and 6/13/2021 to 8/11/2021, included physician orders for skilled nursing services to perform administration of medication injections. b. The patient's clinical record lacked documentation of any updates to the comprehensive assessment except for an assessment of the patient's medications (drug regimen review) after 10/10/2020. 3. Patient #7 had a start of care date of 5/2/2019. Clinical record review revealed the following: a. The Plans of Care, dated 3/9/2021 to 5/7/2021 and 5/8/2021 to 7/6/2021, included physician orders for home health aide services without the provision of skilled services. b. The update to the comprehensive assessment at the time of recertification, dated 5/19/2021, was completed 12 days after the end of the certification period end on 5/7/2021. The assessment narrative documented the visit to complete the update to the comprehensive assessment was done late due to the refusal of the patient to allow the nurse to visit. The home health aide flow sheets (visit notes) documented the aide visited the patient on 5/3/2021 and 5/5/2021, both dates falling between day 56 and 60 of the certification period. The clinical record lacked any documentation of physician notification of the inability to complete the update by day 60 until 5/19/2021, 12 days after the assessment was already late. c. The update to the comprehensive assessment at the time of recertification due during days 56 -60 of the 5/8/2021 to 7/6/2021, had not yet been completed at the time of the survey ending on 7/22/2021, making the assessment at minimum 16 days late. The nurse documented multiple telephone calls to set up visit with the patient hanging up abruptly on the nurse between 7/2/2021 and 7/19/2021. The home health aide flow sheets (visit notes) documented the aide visited the patient on 7/2/2021, which fell between day 56 and 60 of the certification period. The clinical record lacked any documentation of physician notification of the inability to complete the update by day 60. The surveyor reviewed the above stated findings for Patients #5, #6 and #7 with the Administrator. During agency staff interview on 7/21/2021 at 3:00 PM, the Administrator reported Patients #5 and #6 preferred to come into the office to receive services instead of the agency staff going to the patient's home. She reported the agency routinely performed an initial comprehensive assessment with drug regimen review at admission then only completed a skilled nurse visit note each time the patient visited the office to document the tasks performed. A drug regimen review is completed at the end of each certification period and the Plan of Care is updated and sent to the physician for signature. 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 or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, patient interview and agency staff interview, the agency failed to ensure completion of the update to the comprehensive assessment with accompanying drug regimen review within 48 hours of the agency's knowledge of return home from an inpatient facility by performing an onsite assessment of the patient for 2 of 2 sampled patients requiring a resumption of care assessment (Patients #3 and #4). The agency provided services to 43 patients at the time of the survey. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to agency policy, titled Policies and Procedures for Using Outcome and Assessment Information Set (OASIS), dated 10/2003, each patient will receive a patient specific, comprehensive assessment that accurately reflects the client's current health status and includes information that may be used to demonstrate the clients progress toward achievement of desired outcomes. The comprehensive assessment will identify the client's continuing need for home care and meet the client's medical, nursing, rehabilitative, social and discharge planning needs. The comprehensive assessment will be updated and revised within 48 hours of the patient's return from a hospital admission of 24 hours or more for any reason other than diagnostic tests or observation. According to agency policy, titled Medication Profile, dated 10/2003, a Drug Regimen Review (DRR) will be done on all clients when a comprehensive assessment is due. 1. Patient #4 had a start of care date of 5/24/19. Clinical record review revealed: a. The Transfer assessment, dated 4/1/21, documented Patient #4 was hospitalized on 4/1/21. b. A faxed referral for resumption of care to the agency, dated 4/3/21, sent by the hospital and faxed to the agency. c. The update to the comprehensive assessment at the time of resumption of care, dated 4/7/21, documented the patient was discharged from the hospital on 4/3/21. d. The client service record/narrative, dated 4/5/21, documented the resumption of care visit was made on 4/5/21. e. The clinical record did not include a DRR form completed by the nurse at the resumption of care visit. f. Interview on 7/22/21 at 8:47 AM with the agency Administrator revealed the patient was seen and the visit was made within 48 hours, however the nurse did not completed the resumption of care assessment as the nurse thought she had two additional days after requesting for physician guidance regarding the DRR was sent to the physician. The comprehensive assessment was completed by agency staff, 4 days after the patient's return home from the hospital, exceeding the required time frame an additional 48 hours. 2. Patient #3 had a start of care date of 5/20/2021. Clinical record review revealed the following: a. The transfer to inpatient facility, dated 6/24/2021, documented the patient was hospitalized on 6/23/2021. b. The hospital sent a discharge summary of the patient's inpatient stay to the agency by facsimile on 6/26/2021, the date of the patient's discharge from the hospital. c. The update to the comprehensive assessment at the time of resumption of care home visit occurred on 6/28/2021, 2 days after the agency received documentation of the patient's return home. The assessment documented the patient's inpatient hospital discharge date was 6/26/2021 and documented the agency received the referral to resume care on 6/26/2021. The nurse signed the updated assessment as complete on 6/30/2021, 4 days after the agency had knowledge of the patient's return home from the hospital stay. d. On 6/28/2021 the nurse completed a drug regimen review and sent documentation to the physician to report clinically significant findings in the review. The physician signed the document and returned the document back to the nurse on 7/7/2021 acknowledging the report. During agency staff interview on 7/22/2021 at 8:45 AM, the Administrator reported she thought the agency had two days following the visit made for resumption of care. The nurse had sent out the note to the physician to report significant medication changes on 6/28/2021. When no response from the physician occurred in the next 2 days, the nurse then finished adding the physician reporting information into the assessment and signed it off on 6/30/2021, mistakenly thinking this was within the allowed timing for the assessment. The above stated findings for Patients #3 and #4 were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and agency staff interview, the agency failed to ensure completion of all required components of the discharge comprehensive assessments within 2 calendar days of identification of the need to discharge a patient for 2 of 3 sampled patients requiring a discharge comprehensive assessment (Patients #8 and #9). The agency reported a census of 43 patients at the time of the survey and discharged 15 patients in the previous 6 month period. Failure to accurately and thoroughly complete discharge comprehensive assessments in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to agency policy, titled Policies and Procedures for Using Outcome and Assessment Information Set (OASIS), dated 10/2003, each patient will receive a patient specific, comprehensive assessment that accurately reflects the client's current health status and includes information that may be used to demonstrate the clients progress toward achievement of desired outcomes. The comprehensive assessment will identify the client's continuing need for home care and meet the client's medical, nursing, rehabilitative, social and discharge planning needs. The comprehensive assessment will be updated and revised when the patient discharges from the agency or has a death at home. According to the agency's Admission and Discharge criteria, dated 1/13/18, a patient may be discharged when the patient is transferred to a hospital, extended care facility, or another agency when a current plan of treatment has ended. 1. Patient #9 had a start of care date of 10/5/2020 and a discharge date of 6/1/21. Clinical record revealed: a. The Plans of Care, dated 10/5/2020 to 12/3/2020, 12/4/2020 to 2/1/2021, 2/2/2020 to 4/2/21 and 4/3/21 to 6/1/21, included physician orders for skilled nursing and home health aide services. b. The update to the comprehensive assessment for recertification, dated 12/3/21, documented the patient reported plans to go to a nursing home for the winter and plans to return home in the spring and would like to continue with current services and Plan of Care with no changes when returns home. c. A faxed Patient Summary, dated 1/13/21, informed the physician the patient is going to a nursing home for the winter this week, but the agency would keep the patient on services as the patient planned to return home in the spring. d. An update to the Plan of Care, dated 2/1/21, included new orders for the patient for the certification period 2/2/21 through 4/2/21. e. An update to the Plan of Care, dated 3/29/21, included new orders for the patient for the certification period 4/3/21 through 6/1/21. f. A faxed Patient Summary, dated 3/29/21, informed the physician the patient is still in the nursing home and the agency would perform recertification assessment when patient returns home. g. A faxed discharge summary, dated 6/1/21, documented the patient was admitted to the agency on 10/5/2020 and last seen by the agency on 12/3/21. The patient was discharged on 6/1/21 due to no return home from the nursing home. h. The clinical record lacked evidence of agency staff discharged the patient as stated in the agency's Admission and Discharge criteria. According to the agency policy, titled Office Visits Clients and dated 10/2003, the agency will provide office visits to patients who wish to be seen in the office and have a skilled nursing need. An evaluation will be made assessing the patient's living situation/condition, health status, cardiovascular status, respiratory status, elimination status, eyes/hearing, nutritional status, pain status, integument, musculoskeletal status, mental health, activities of daily living, social network and activities. The agency will also assess the patient's medications as part of the drug regimen review. The policy lacked any identification of how often the above stated assessments should be performed. 2. Patient #8 had a start of care date of 6/8/2021 and paid privately for agency services, receiving skilled nurse visits in the home health office. The patient was discharged from agency services on 7/6/2021. Clinical record revealed the following: a. The Plan of Care, dated 6/8/2021 to 8/6/2021, included physician orders for skilled nursing services to perform wound care dressing changes to the patient's surgical incision. b. The patient's clinical record lacked documentation of an update to the comprehensive assessment at the time of discharge. The surveyors reviewed the above stated findings for Patients #8 and #9 with the Administrator. During agency staff interview on 7/21/2021 at 3:00 PM, the Administrator reported Patient #8 preferred to come into the office to receive services instead of the agency staff going to the patient's home. She reported the agency routinely performed an initial comprehensive assessment with drug regimen review at admission then only completes a skilled nurse visit note each time the patient visited the office to document the tasks performed. The agency provided no additional information prior to the end of the survey.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient/caregiver interview and agency staff interview, the agency: 1) failed to admit patients to service based on the reasonable expectation the agency could meet the patient's medical, nursing, rehabilitative and social needs in the patient's place of residence (G570); 2) failed to ensure staff followed the Plan of Care as ordered by the physician or notified the physician in a timely manner if unable to follow the Plan of Care (G572); 3) failed to ensure all supplies/equipment/medications/treatments required by the patient to meet his/her needs were included and accurate on each patient's Plan of Care (G574); 4) failed to administer medications, treatments and services only as ordered by a physician (G580); and 5) failed to promptly alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or the plan of care should be altered (G590). The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 43 patients. Based on clinical record review, agency policy review and agency staff interview, the agency failed to admit patients to service based on the reasonable expectation the agency could meet the patient's medical, nursing, rehabilitative and social needs in the patient's place of residence for 3 of 8 sampled patients (Patients #5, #6 and #8). The agency reported a current census of 43 patients, including 2 currently receiving all skilled nursing services in the agency office and not in the patient' homes. Failure to provide services in the patient's place of residence placed agency patient's at risk for unidentified needs presented in the home setting. Findings include: According to the agency policy, titled Office Visits Clients and dated 10/2003, the agency will provide office visits to patients who wish to be seen in the office and have a skilled nursing need. 1. Patient #5 had a start of care date of 10/8/2020 and received office visits from the agency. The patient paid privately for skilled nursing visits. Clinical record review revealed the following: a. The Plans of Care, dated 10/8/2020 to 12/6/2020, 12/7/2020 to 2/4/2021, 2/5/2021 to 4/5/2021, 4/6/2021 to 6/4/2021 and 6/5/2021 to 8/3/2021, included physician orders for skilled nursing services to perform administration of medication injections. b. The clinical record included skilled nursing office visit notes, dated 11/5, 12/3, 12/31/2020; 1/28, 2/25, 3/25, 4/5, 4/12, 4/19, 4/22, 4/26, 5/4, 5/11, 5/19, 5/21, 5/25, 6/8, 6/15, 6/17, 6/22, 6/29, 7/1, 7/6, 7/13, 7/15 and 7/19/2021. The patient received all skilled nursing visits in the home health office instead of receiving services in the patient's place of residence. c. The clinical record lacked any documentation indicating the registered nurse ever visited the patient's home for assessment or provision of care. 2. Patient #6 had a start of care date of 10/31/2016 and received office visits from the agency. The patient paid privately for skilled nursing visits. Clinical record revealed the following: a. The Plans of Care, dated 10/16/2020 to 12/14/2020, 12/15/2020 to 2/12/2021, 2/13/2021 to 4/13/2021, 4/14/2021 to 6/12/2021 and 6/13/2021 to 8/11/2021, included physician orders for skilled nursing services to perform administration of medication injections. b. The clinical record included skilled nursing office visit notes, dated 11/2/2020, 12/7/2020, 1/4/2021, 2/1/2021, 3/1/2021, 4/5/2021, 5/3/2021, 6/1/2021 and 7/6/2021. The patient received all skilled nursing visits in the home health office instead of receiving services in the patient's place of residence. c. The clinical record lacked any documentation indicating the registered nurse ever visited the patient's home for assessment or provision of care. 3. Patient #8 had a start of care date of 6/8/2021 and received office visits from the agency. The patient paid privately for skilled nursing visits. The patient was discharged from agency services on 7/6/2021. Clinical record revealed the following: a. The Plan of Care, dated 6/8/2021 to 8/6/2021, included physician orders for skilled nursing services to perform wound care dressing changes to the patient's surgical incision. b. The clinical record included skilled nursing office visit notes, dated 6/8, 6/9, 6/10, 6/11, 6/15, 6/16, 6/21 and 6/23/2021. The patient received all skilled nursing visits in the home health office instead of receiving services in the patient's place of residence. c. The clinical record lacked any documentation indicating the registered nurse ever visited the patient's home for assessment or provision of care. The above stated findings for Patients #5, #6 and #8 were reviewed with the Administrator. During agency staff interview on 7/21/2021 at 3:00 PM, the Administrator reported Patients #5 and #6 preferred to come into the office to receive services instead of the agency staff going to the patient's home. The agency provided no additional information prior to the end of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review, patient interview and agency staff interview, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 5 of 8 sampled patients (Patients #2, #4, #5, #8 and #10). The agency reported a census of 43 patients at the time of the survey. Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. Findings include: According to the agency policy, titled Plan of Care, dated 10/2003, the Plan of Care shall be completed in full to include frequency and duration of visits to be made, and treatments to be performed. Professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care. A range in frequency of visits for each service may be ordered by the physician. If fewer visits are provided than the minimum ordered, the physician will be notified when the next 60 day summary is done. According to the undated agency policy, titled Wound Care, assessment and documentation of wound measurements/wound characteristics will occur weekly and as needed. During agency staff interview on 7/19/2021 at 3:15 PM, the Administrator revealed agency staff document wound care and measurements in the nurse's visit notes. Measurements are to be performed weekly and include length, width, and depth. During agency staff interview on 7/20/2021 at 9:14 AM, the Administrator revealed agency staff do a verbal order if extra visits are made to a patient and notify the physician of any missed visits every 60 days on the 60 day summary. 1. Patient #2 had a start of care date of 3/17/21. Clinical record review revealed: a. The Plan of Care, dated 5/16/21 through 7/14/21, included physician orders for skilled nursing visits three times per week for 60 days to perform dressing changes. b. The week of 5/23/21, the clinical record included only two skilled nursing visits on 5/24/21 and 5/26/21. c. The week of 5/30/21, the clinical record included only two skilled nursing visits on 5/31/21 and 6/2/21. d. The week of 6/13/21, the clinical record included only two skilled nursing visits on 6/14/21 and 6/16/21. e. The week of 6/27/21, the clinical record included only two skilled nursing visits on 6/28/21 and 6/30/21. f. The 60 day progress report, dated 7/14/21, documented the skilled nurse did not make visits on 5/28, 6/4, 6/18, and 7/2/21 as the patient's dressings were performed at the wound clinic. g. The clinical record lacked providing timely notification of the missed visit to the physician to allow the physician to decide whether or not the treatment may be skipped or whether additional intervention was required by the agency due to the clinical impact on the patient. h. The Plans of Care, dated 4/19/21 through 6/17/21, included physician orders for the nurse to assess the patient for pain, blood pressure, pulse, chest pain, shortness of breath, medication compliance and edema. i. The skilled nursing visit note, dated 5/17/21, lacked assessment of pain or medication compliance. j. The skilled nursing visit note, dated 5/19/21, 5/21/21, and 7/12/21, lacked assessment of pain, blood pressure, pulse, chest pain, shortness of breath, medication compliance and edema. k. The skilled nursing visit note, dated 5/21/21, 6/2/21, 6/7/21, 6/14/21, 6/21/21, lacked assessment of medication compliance. l. The skilled nursing visit note, dated 5/31/21, lacked assessment of pain, blood pressure, pulse, medication compliance and edema. m. The skilled nursing visit note, dated 6/9/21, 6/11/21, 6/16/21, 6/23/21, 6/30/21, lacked assessment of blood pressure, pulse, chest pain, shortness of breath, medication compliance and edema. n. The skilled nursing visit note, dated 6/25/21, lacked assessment of blood pressure, pulse, and edema. o. The skilled nursing visit note, dated 7/7/21, lacked assessment of blood pressure, pulse, medication compliance and edema. p. The skilled nursing visit note, dated 7/9/21, lacked assessment of blood pressure and pulse. The clinical record lacked providing timely notification of the missed treatments to the physician to allow the physician to decide whether or not the treatment may be skipped or whether additional intervention was required by the agency due to the clinical impact on the patient. 2. Patient #4 had a start of care date of 5/24/19. Clinical record review revealed: a. The Plans of Care, dated 5/13/21 through 7/11/21 and 7/12/21 through 9/9/21, included physician orders for skilled nursing visits weekly for 60 days and included interventions for the nurse to assess medication compliance and sleep. b The skilled nursing visit note, dated 5/19/21, lacked assessment of medication compliance or sleep. c. The skilled nursing visit note, dated 5/26/21 and 6/16/21, lacked assessment of sleep. d. The skilled nursing visit note, dated 6/2/21 and 6/9/21, lacked assessment of medication compliance. The clinical record lacked providing timely notification of the missed treatments to the physician to allow the physician to decide whether or not the treatment may be skipped or whether additional intervention was required by the agency due to the clinical impact on the patient. 3. Patient #10 had a start of care date of 10/12/2020 and a discharge date of 3/29/2021. Clinical record review revealed: a. The Plan of Care, dated 12/11/2020 through 2/8/201, included physician orders for skilled nursing visits one time every two weeks for 60 days and included physician orders for the nurse to assess the patient for edema. b. The skilled nursing visit notes, dated 2/17/21, lacked assessment of edema. The clinical record lacked providing timely notification of the missed treatment to the physician to allow the physician to decide whether or not the treatment may be skipped or whether additional intervention was required by the agency due to the clinical impact on the patient. 4. Patient #5 had a start of care date of 10/8/2020. Clinical record review revealed the following: a. The Plans of Care, dated 4/6/2021 to 6/4/2021 and 6/5/2021 to 8/3/2021, included physician orders for skilled nursing visits once weekly to assess for infection (temperature monitors infections in the body), assess the patient's heart rate, assess the patient's blood pressure and administer the medications Stelara (every 4 weeks) and Methotrexate (weekly) by injection. b. The skilled nurse visit notes, dated 4/19, 4/26, 5/4, 5/11,5/19, 5/25, 6/2, 6/8, 6/15, 6/22 6/29, 7/13 and 7/19/2021, lacked documentation the nurse assessed the patient's temperature, heart rate or blood pressure as ordered by the physician. 5. Patient #8 had a start of care date of 6/8/2021 and was discharged from agency services on 7/6/2021. Clinical record review revealed the following: a. The Plan of Care, dated 6/8/2021 to 8/6/2021, included physician orders for skilled nursing visits 5 times per week to perform wound care/dressing changes to the patient's right shoulder surgical incision Monday through Friday each week; assess for infection; measure the wounds weekly and confer with the physician as needed. b. The skilled nurse visit notes, dated 6/15 and 6/16/2021, lacked any wound measurements. The clinical record lacked documentation of any further visits during the week of 6/13-19/2021. The wounds did not get measured that week and the skilled nurse only made 2 visits of the 5 ordered by the physician. The clinical record lacked documentation of the reason for omission of the visits and lacked documentation of physician notification of the missed visits. c. The skilled nurse visit notes, dated 6/21 and 6/23/2021, lacked any wound measurements. The clinical record lacked documentation of a missed visit on 6/22/2021 as the patient did not show for the appointment. The wounds did not get measured that week and the clinical record lacked any documentation indicating the physician was notified of the missed visit on 6/22/2021. The above stated findings for Patients #2, #4, #5, #8 and #10 were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation, patient and patient caregiver interview and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and accurate medication orders for 4 of 8 sampled patients (Patients #1, #2, #3, and #4,). The agency reported a current census of 43 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: According to agency policy, titled Plan of Care, dated 10/2003, the individualized plan of care must include the following: all pertinent diagnoses, the patient's mental, psychosocial and cognitive status, types of services, supplies and equipment required, frequency and duration of visits to be made, prognosis, rehabilitation potential, functional limitations, activities, nutritional requirements, medications and treatments, safety measures to protect against injury, description of the patient's risk for emergency hospitalization and hospital readmission and all necessary interventions to address underlying risk factors, patient and caregiver education to facilitate timely discharge, patient and caregiver specific interventions and education, measurable outcomes and goals identified by the agency and patient, information related to advance directives, any additional items the home health agency of physician may choose to include, and the name and address of the patient's physician. 1. Patient #1 had a start of care date of 12/28/2020. Clinical record review revealed: a. The Plans of Care, dated 4/19/21 through 6/17/21 and 6/18/21 through 8/16/21, included physician orders for skilled nursing visits 1 times per week for 60 days and home health aide visits two times per week for 60 days. b. The Plans of Care identified the following medical equipment and supplies as used by the patient: walker, commode, medication box, grab bars, shower chair, and oxygen supplies. c. The initial comprehensive assessment completed at start of care, dated 2/23/21, documented the patient was incontinent of urine. d. The updates to the comprehensive assessment for recertication, dated 4/14/21 and 6/15/21, documented the patient was incontinent of urine. e. During a home visit observation on 7/20/21 at 11:18 AM with Staff B, Registered Nurse (RN), interview with the patient's caregiver reported the patient's use of incontinent supplies since April of last year (2020). f. The Plans of Care, lacked inclusion of incontinence supplies as supplies used to meet the patient's needs. g. A verbal physician's order, dated 7/13/21, included orders for albuterol sulfate 2.5 milligrams (mg) per 3 milliliters (ml) to be used every four hours as needed for difficulty breathing. h. During the same home visit, interview with the patient's caregiver, reported the patient's use of the nebulizer for the past forty five days. i. The Plans of Care, lacked inclusion of nebulizer as supplies used to meet the patient's needs. j The skilled nursing visit note, dated 6/15/21, documented the patient was not wearing lifeline bracelet as the bracelet caused bruising of the patient's wrist and the nurse encouraged wearing the lifeline as a necklace. k. During the same home visit, interview with the patient's caregiver, reported the patient has had the Lifeline since the patient started receiving services with the agency. l. The Plans of Care, lacked inclusion of Lifeline as supplies used to meet the patient's needs. m. The Plans of Care included medication orders for Metoprolol 25 milligrams (mg) orally twice daily. n. The initial fax from the physician, included metoprolol succinate extended release (ER) to be take twice daily, with a start date of 2/3/21. o. During the same home visit observation, the surveyor observed the nurse performing weekly medication set up in a medication planner. The surveyor observed the patient's medication bottle which stated Metoprolol ER 25 mg and instructed use for twice daily. p. The Plans of Care lacked inclusion of Metoprolol ER as ordered by the physician. 2. Patient #2 had a start of care date of 3/17/21. Clinical record review revealed: a. The Plans of Care, dated 3/17/21 through 5/15/21, 5/16/21 through 7/14/21, 7/15/21 through 9/12/21, identified the following equipment and supplies used to meet the patient's needs: wound supplies, catheter supplies, compression stockings, hoyer lift, wheelchair, shower chair, stool riser, grabber, and transfer board. b. During home visit observation on 7/21/21 at 7:53 AM, the surveyor accompanied Staff B, Registered Nurse (RN) to Patient #2's home. During the home visit the surveyor reviewed supplies and equipment used by the patient. The surveyor observed the patient was laying on two hospital beds pushed together upon entry to home. The patient reported use of the two beds for several years, noting to the surveyor, I have been in a wheelchair for 37 years. The surveyor observed two hand braces hanging above the hospital bed. The patient reported use of the braces for carpal tunnel and stated use of them if arms are sore. The surveyor also noted the patient also had an electric wheelchair next to the beds with a roho cushion on it. The patient reported use the cushion for 1-2 years. The surveyor reviewed the patient's medications with the patient. The patient is independent with medications and sets medications up weekly in a medication planner. c. The Plans of Care, dated 3/17/21 through 5/15/21, 5/16/21 through 7/14/21, 7/15/21 through 9/12/21 , lacked identification of the hospital bed, roho cushion, hand braces, and medication planner as equipment used to meet the needs of the patient. d. The Plans of Care, dated 5/16/21 through 7/14/21, 7/15/21 through 9/12/21, included an order for Vitamin C 500 mg every noon and evening and 1000 mg every morning. e. During the same home visit, the surveyor reviewed the medications used by the patient in the home. The patient's medications were stored in the kitchen. The surveyor observed a bottle of Vitamin C 500 mg. The patient reported currently taking 1 tablet in the morning, 1 at supper, and 1 at bedtime. The Plans of Care, dated 5/16/21 through 7/14/21, 7/15/21 through 9/12/21, failed to include the dosage of Vitamin C used by the patient. 3. Patient #4 had a start of care date of 5/24/19. Clinical record review revealed: a. The Plans of Care, dated 5/24/21 through 7/22/19, 3/14/21 through 5/12/21, 5/13/21 through 7/11/21, and 7/12/21 through 9/9/21, identified the following equipment and supplies used to meet the patient's needs: cane, grab bars, lift chair and walker. a. The initial skilled nursing visit note, dated 5/24/19, documented the patient was incontinent of bladder and bowels and wears an adult brief for protection. b. The initial comprehensive assessment at start of care, dated 5/29/19, documented the patient was incontinent. c. The updates to the comprehensive assessment for recertification, dated 3/10/21, 5/12/21, and 7/7/21, documented the patient was incontinent. d. The update to the comprehensive assessment for resumption of care, dated 4/7/21, documented the patient was incontinent. e. The Plans of Care, dated 5/24/21 through 7/22/19, 3/14/21 through 5/12/21, 5/13/21 through 7/11/21, and 7/12/21 through 9/9/21, lacked identification of incontinence supplies as equipment used to meet the needs of the patient. 4. Patient #3 had a start of care date of 5/20/2021. Clinical record review revealed the following: a. The Plans of Care, dated 5/20/2021 to 7/18/2021 and 7/19/2021 to 9/16/2021, included physician orders for magnesium 400 milligrams one tablet three times daily. Home visit observation and associated interviews revealed the following: b. On 7/21/2021 at 11:30 AM, the surveyor accompanied Staff C, RN, to Patient #3's home. During the home visit, Staff C, RN, set up 7 days of the patient's medications in a weekly medication planner. During the medication set up, the surveyor observed a bottle of magnesium 500 milligram tablets in the home. The bottle originally held 30 tablets and had only 10 remaining. c. During patient interview on 7/21/2021 during the home visit, Patient #3 reported she had been taking the magnesium 500 milligrams out of the bottle once daily since opening the bottle. d. The nurse performed a drug regimen review the previous week on 7/14/2021 and did not identify the discrepancy between the dose and frequency the patient was actually taking and the dose and frequency ordered by the physician. e. The nurse updated the Plan of Care, dated 7/19/2021 to 9/16/2021, on 7/14/2021 without updating the magnesium order on the Plan of Care to reflect the dose and frequency currently taken by the patient. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to provide services only as ordered by the physician for 2 of 8 sampled patients (Patients #5 and #7). The agency reported a current patient census of 43 patients. Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: 1. Patient #5 had a start of care date of 10/8/2020. Clinical record review revealed the following: a. The Plans of Care, dated 4/6/2021 to 6/4/2021 and 6/5/2021 to 8/3/2021, included physician orders for skilled nursing visits once weekly to assess for infection (temperature monitors infections in the body), assess the patient's heart rate, assess the patient's blood pressure and administer the medications Stelara (every 4 weeks) and Methotrexate (weekly) by injection. b. The clinical record included documentation of 2 skilled nurse visits during the weeks of 4/18-24/2021; 5/16-5/22/2021; 6/13-19/2021 and 7/11-17/2021. The physician orders were for only one visit every week. c. During agency staff interview on 7/22/2021 at 9:00 AM, the Administrator reported the University of Iowa pharmacy had recommended giving the Stelara and Methotrexate injections on different days when administered during the same week so the agency had followed that recommendation. The Administrator concurred the nurse had not obtained physician approval/order for the second visit during the above stated weeks when separating out the injections to different days. 2. Patient #7 had a start of care date of 5/2/2019. Clinical record review revealed the following: a. The Plans of Care, dated 3/9/2021 to 5/7/2021 and 5/8/2021 to 7/6/2021, included physician orders for home health aide services without the provision of skilled services. b. The update to the comprehensive assessment at the time of recertification, dated 5/19/2021, was completed 12 days after the end of the certification period end on 5/7/2021. The assessment narrative documented the visit to complete the update to the comprehensive assessment was done late due to the refusal of the patient to allow the nurse to visit. The clinical record lacked any documentation of physician notification of the inability to complete the update by day 60 until 5/19/2021, 12 days after the assessment was already late. The clinical record lacked any physician orders approving the agency to continue to provide care according to the previous Plan of Care until the assessment could be completed and the Plan of Care updated. The home health aide flow sheets (visit notes) documented the aide visited the patient on 5/14/2021 without physician orders to do so. c. The update to the comprehensive assessment at the time of recertification due during days 56 -60 of the 5/8/2021 to 7/6/2021, had not yet been completed at the time of the survey ending on 7/22/2021, making the assessment at minimum 16 days late. The nurse documented multiple telephone calls to set up visit with the patient hanging up abruptly on the nurse between 7/2/2021 and 7/19/2021. The clinical record lacked any documentation of physician notification of the inability to complete the update by day 60. The clinical record lacked any physician orders approving the agency to continue to provide care according to the previous Plan of Care until the assessment could be completed and the Plan of Care updated. The home health aide flow sheets (visit notes) documented the aide visited the patient on 7/9,12,14/2021 without physician orders to do so. The above stated findings for Patients #3 and #7 were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to notify the physician of changes that suggest a need to alter the Plan of Care for 1 of 8 sampled patients (Patient #8). The agency reported a current census of 43 patients. Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: According to the agency policy, titled Plan of Care and dated 10/2003, the professional staff shall promptly alert the physician to any changes that suggest a need to alter the Plan of Care. Patient #8 had a start of care date of 6/8/2021 and was discharged from agency services on 7/6/2021. Clinical record review revealed the following: a. The Plan of Care, dated 6/8/2021 to 8/6/2021, included physician orders for skilled nursing visits 5 times per week to perform wound care/dressing changes to the patient's right shoulder surgical incision Monday through Friday each week; assess for infection; measure the wounds weekly and confer with the physician as needed. b. The clinical record lacked any skilled nursing visits for wound care after 6/23/2021. The nursing progress notes narrative, dated 6/24, 6/25, 6/28, 6/29, 6/30, 7/1 7/2, 7/5 and 7/6/2021, documented the patient stopped coming to the home health office for skilled nursing services to change the patient's dressing and perform wound care. The notes documented telephone calls to the patient were unsuccessful in either contact or in getting the patient to show up after an appointment was set up. c. The clinical record lacked any documentation of contact with the physician to report the inability to perform the dressing change/wound care as ordered for 9 consecutive days until after the patient was discharged on 7/6/2021 at the patient's request. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

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 personnel file review and agency staff interview, the agency failed to ensure 1 of 2 sampled home health aides (Staff D), demonstrated completion of all basic skills prior to providing care independently to any of the home health agency patients. The agency reported a current census of 43, including 20 patients who received home health aide services at the time of the survey. The agency employed 3 home health aides at the time of the survey. Failure to ensure that home health aides demonstrated completion of all of the assigned basic skills while observed by a registered nurse (RN) to determine competency in each task prior to being allowed to care for agency patients independently, increased the potential risk of harm to the patient. Findings include: Personnel file review revealed the following: Home Health Aide D had a hire date of 6/21/2021. Her personnel file included a basic competency check list and individual pages for each required basic competency which documented when the task was competency tested, where and by whom. Home Health Aide D's personnel file lacked documentation of demonstrated competency by an RN for bathing in a tub, shampoo in a tub and range of motion, all required basic skills. The surveyor reviewed the above stated findings with the Administrator. During agency staff interview on 7/22/2021 at 10:05 AM, the Administrator reported the agency only has one patient who takes a tub bath, shampoos in the tub and has range of motion. The Administrator planned to take the aide to perform theses tasks some time in the future but had not yet done so. The Administrator reported Home Health Aide D provided care independently to agency patients but was not assigned to any patients requiring tub bath, shampoo in the tub or range of motion until the competency could be completed. The agency provided no additional information prior to the end of the survey.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, home visit observation and staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 2 of 5 sampled patients receiving home health aide services (Patients #1 and #2). The agency reported a current census of 43 patients at the time of the survey, including 20 who received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient and according to the home health aide care plan increased the risk that patients' personal care needs were not adequately met. Findings including: According to the agency policy, titled Home Care Aide Services and dated 10/2003, the home health aide services will be provided to appropriate patients on an intermittent, or part-time basis, under the direct supervision on an agency nurse in accordance with a medically approved Plan of Care. According to the agency policy, titled Plan of Care and dated 10/2003, home care services are furnished under the supervision and direction of the patient's physician. The Plan of Care is written and regularly approved by a physician, serves as a measurable guideline to care given by all professional disciplines involved in patient care, and meets state/federal guidelines and all applicable laws and regulations. During entrance interview on 7/19/21 at 3:15 PM, agency Administrator revealed the nurse caring for the patient creates the care plan and reviews the care plan. 1. Patient #1 had a start of care date of 2/18/21. Clinical record review revealed: a. The home health aide assignment flowsheets, dated 5/1/21 through 7/15/21, included direction to the aide to use a gait belt for transfers. Use of a gait belt is an extension of nursing services, thereby requiring physician approval for the aide to perform the task. The Plans of Care, dated 4/19/21 through 6/17/21 and 6/18/21 through 8/16/21, lacked physician approval for the home health aide to use a gait belt for transfers as an extension of nursing services. 2. Patient #2 had a start of care date of 3/17/21. Clinical record review revealed: a. The home health aide assignment flowsheets, dated 5/16/21 through 7/15/21, included direction to the aide to apply compression hose. Application of compression hose is an extension of nursing services, thereby requiring physician approval for the aide to perform the task. The Plans of Care, dated 5/16/21 through 7/14/21 and 7/15/21 through 9/12/21, lacked physician approval for the home health aide to apply compression hose as an extension of nursing services. The above findings for Patients #1 and #2 were reviewed with agency Administrator. Agency staff provided no further information prior to the end of the survey.

Non-skilled direct observation every 60 days CFR(s): 484.80(h)(2) If home health aide services are provided to a patient who is not receiving skilled nursing care, physical or occupational therapy, or speech-language pathology services, the registered nurse must make an on-site visit to the location where the patient is receiving care no less frequently than every 60 days in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on clinical record review and agency policy review, the agency failed to ensure a registered nurse completed home health aide supervision at least every 60 days while observing the home health aide present and providing direct patient care for 1 of 2 sampled patients who received hands on personal care services with no skilled service provision. (Patient #7). The agency reported a current census of 43 patients, including 9 patients who received personal care assistance by a home health aide without any skilled service provision. Failure to supervise home health aide services, at least every 60 days while the aides provided direct patient care, increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency policy, titled Home Care Aide/Homemaker Supervision and dated 12/2014, when only home health aide services are being furnished, the nurse must make a supervisory visit to the patient's residence at least once every 60 days. Each supervisory visit must occur when the aide is providing direct patient care. Patient #7 had a start of care date of 5/2/2019. Clinical record review revealed the following: The Plans of Care, dated 11/9/2020 to 1/7/2021, 1/8/2021 to 3/8/2021, 3/9/2021 to 5/7/2021 and 5/8/2021 to 7/6/2021, included physician orders for home health aide services without the provision of skilled services. The aide supervisory note, dated 11/5/2021, documented indirect supervision of the home health aide during a visit with the patient when the home health aide was not present. The clinical record lacked documentation of any other supervisory visits associated with the 60 day period prior to the 11/9/2020 to 1/7/2021 certification period. The aide supervisory note, dated 3/8/2021, documented aide supervision when the aide was in the home and providing direct patient care. The next supervisory visit occurred on 5/19/2021, 72 days later. At the time of the surveyor's clinical record review on 7/21/2021, 63 days after the last supervisory visit, the record lacked any further documentation of aide supervision. The above stated findings were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to ensure authentication of staff documentation in each patient's clinical record included the date and time of the employee signature for 8 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6, #7, and #8). The agency reported a current census of 43 patients at the time of the survey. Failure to maintain appropriately authenticated clinical record documentation increased the risk that agency staff provided services without up to date information related to the patient's condition, and decreased the ability of agency staff to communicate effectively in order to coordinate patient care. Findings include: Interview with agency Administrator on 7/20/21 at 9:14 AM, revealed staff are to complete documentation as soon as possible, but for sure within one week of visit occurrence. The nurse chart on notebooks in the home and return to the office to complete the nursing visit notes in the computer. Interview during a home visit on 7/20/21 beginning at 11:18 AM with Staff B, Registered Nurse (RN), revealed the nurse's chart in the home and perform charting back at the office within a day or two of the visits. 1. Patient #1 had a start of care date of 2/18/21. The Plans of Care, dated 2/18/21 through 4/18/21, 4/19/21 through 6/17/21, and 6/18/21 through 8/16/21, included orders for skilled nursing and home health aide services. Clinical record review revealed: a. The skilled nursing visit note, dated 2/18/21, was hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. b. The initial comprehensive assessment for start of care, dated 2/23/21, was hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. c. The updates to the comprehensive assessment for recertification, dated 4/14/21 and 6/15/21, were hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. d. The skilled nursing visit notes, dated 4/14, 5/18, 5/25, 6/1, 6/8, 6/15, 6/22, 6/29, 7/6 and 7/13/21 completed by the nurse were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit.. e. The home health aide flowsheet (visit notes), dated 5/11, 5/14, 5/17, 5/21, 5/24, 5/26, 6/1, 6/2, 6/4, 6/7, 6/14, 6/18, 6/21, 6/22, 6/24, 7/2, 7/6 and 7/13, included the date of the visit, time of initiation of the visit and the time the visit ended; however, lacked a complete signature including title of discipline, date, and time signifying completion of the documentation of the visit. 2. Patient #2 had a start of care date of 3/17/21. The Plans of Care, dated 3/17/21 through 5/15/21, 5/16/21 through 7/14/21, and 7/15/21 through 9/12/21, included orders for skilled nursing and home health aide services. Clinical record review revealed: a. The skilled nursing visit notes, dated 3/17/21, 3/19/21 and 3/22/21, was hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. b. The initial comprehensive assessment for start of care, dated 3/22/21, was hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. c. The updates to the comprehensive assessment for recertification, dated 5/12/21 and 7/14/21, were hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. d. The skilled nursing visit notes, dated 5/10, 5/12, 5/17, 5/19, 5/21, 5/24, 5/26, 5/28, 5/31, 6/2, 6/7, 6/9, 6/11, 6/25, 6/30, 7/2, 7/5, 7/7, 7/9, 7/12, and 7/16/21, completed by the nurse were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. e. The skilled nursing visit notes, dated 6/14, 6/16, 6/18, 6/21, and 6/23/21, completed by the nurse completing the visit, included the date of the visit, time of initiation of the visit and time the visit ended and the nurse's initials at the end of the visit note. The note lacked the nurse's signature, including title, date and time signifying completion of the documentation of the visit. f. The home health aide flowsheet (visit notes), dated 5/17, 5/21, 5/24, 5/28, 6/1, 6/4, 6/7, 6/18, 6/21, 6/25, 6/25, 6/28, 7/2, 7/6, 7/9, and 7/12/21, included the date of the visit, time of initiation of the visit and the time the visit ended; however, lacked a complete signature including title of discipline, date, and time signifying completion of the documentation of the visit. 3. Patient #4 had a start of care date of 5/24/19. The Plans of Care, dated 5/24/19 through 7/22/19, 3/14/21 through 5/12/21, 5/13/21 through 7/11/21, and 7/12/21 through 9/9/21, included orders for skilled nursing. Clinical record review revealed: a. The skilled nursing visit notes, dated 5/24/19 and 5/28/19, were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. b. The initial comprehensive assessment for start of care, dated 5/29/19, was hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. c. The updates to the comprehensive assessment for recertification, dated 3/10/21, 5/12/21 and 7/7/21, were hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. d. The updates to the comprehensive assessment for transfer to inpatient facility dated 4/1/21, was hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. e. The updates to the comprehensive assessment for resumption of care, dated 4/7/21, was hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. f. The skilled nursing visit notes, dated 3/10, 4/5, 5/12, 5/19, 5/26, 6/2, 6/9, 6/16, 6/23, and 7/7/21, completed by the nurse were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. 4. Patient #10 had a start of care date of 10/12/2020 and a discharge date of 3/29/21. The Plans of Care, dated 10/12/2020 through 12/10/2020, 12/11/2020 through 2/8/21, and 2/9/21 through 4/9/21, included orders for skilled nursing. Clinical record review revealed: a. The skilled nursing visit note, dated 10/12/2020, completed by the nurse completing the visit, included the date of the visit, time of initiation of the visit and time the visit ended and the nurse's initials at the end of the visit note. The note lacked the nurse's signature, including title, date and time signifying completion of the documentation of the visit. b. The initial comprehensive assessment for start of care, dated 10/14/2020, was hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. c. The updates to the comprehensive assessment for recertification, dated 12/7/2020 and 2/8/21, were hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. d. The updates to the comprehensive assessment for discharge from agency dated 3/29/21, was hand signed by the registered nurse (RN) with title and date; however, lacked a time of signature. e The skilled nursing visit notes, dated 12/7/2020, 2/1/21, 2/2/21, 2/8/21, 2/17/21, 3/1/21, 3/16/21, and 3/29/21, completed by the nurse were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit.5. Patient #3 had a start of care date of 5/20/2021. Clinical record review and accompanying interviews revealed the following: The Plans of Care, dated 5/20/2021 to 7/18/2021 and 7/19/2021 to 9/16/2021, included orders for skilled nursing and home health aide services. a. The initial comprehensive assessment completed at admission to home health services, dated 5/20/2021, was hand signed by the RN and dated; however, lacked a time of signature. b. The update to the comprehensive assessment completed at the time of transfer to an inpatient facility, dated 6/24/2021, was hand signed by the RN and dated; however, lacked a time of signature. c. The update to the comprehensive assessment completed at the time of resumption of care, dated 6/28/2021, was signed by the RN and dated; however, lacked a time of signature. d. The update to the comprehensive assessment completed at the time of recertification, dated 7/14/2021, was hand signed by the RN and dated; however, lacked a time of signature. e. The skilled nursing visit notes, dated 5/26, 6/2, 6/9, 6/16, 6/23, 7/7 and 7/14/2021, were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. f. The home health aide visit flow sheet (visit notes), dated 5/24, 5/27, 6/1, 6/8, 6/10, 6/15, 6/18, 6/22, 6/28, 7/2, 7/6, 7/9 and 7/13/2021, documented two full weeks of service. Each flow sheet was hand signed by the home health aide once, documenting the aide had received and understood the instructions. The signature did not include credentials, date or time of signature. Each visit note included initials of the aide each visit documenting completion of each task, the date of each visit, the time of initiation of the visit and time the visit ended. The aide notes were also signed by the RN who completed the flow sheet instructions; however, lacked a date and time of the signature. g. The clinical record lacked documentation of a drug regimen review to accompany the update to the comprehensive assessment at the time of resumption of care. On 7/22/2021, after the surveyor presented the findings for the clinical record review, the Administrator presented a drug regimen review, dated 6/28/2021 and signed by Staff C, RN, on 6/28/2021. During agency staff interview, the Administrator reported the nurse completed the drug regimen review at the time of the resumption of care update; however, forgot to print the document for the hard copy chart. During agency staff interview on 7/22/2021 at 9:15 AM, Staff C, RN, reported she had entered the information for the drug regimen review into the patient's clinical record on 6/28/2021 but forgot to print the document for signature. Staff C, RN, reported printing the document on 7/22/2021 and signed the document on 7/22/2021; however, dated the signature 6/28/2021 "as I thought I should as I did it on 6/28/2021." The nurse backdated the signature of the document. 6. Patient #5 had a start of care date of 10/8/2020. Clinical record review revealed the following: The Plans of Care, dated 10/8/2020 to 12/6/2020, 12/7/2020 to 2/4/2021, 2/5/2021 to 4/5/2021, 4/6/2021 to 6/4/2021 and 6/5/2021 to 8/3/2021, included orders for skilled nursing services. a. The initial comprehensive assessment completed at admission to home health services, dated 10/8/2020, was hand signed by the RN and dated; however, lacked a time of signature. b. The update to the comprehensive assessment completed at the time of recertification, dated 12/3/202, was hand signed by the RN and dated; however, lacked a time of signature. c. The skilled nursing visit notes, dated 11/5, 12/3 and 12/31/2020; 1/28, 2/25, 3/25, 4/5, 4/12, 4/19, 4/22, 4/26, 5/4, 5/11, 5/19, 5/21, 5/25, 6/8, 6/15, 6/17, 6/22, 6/29, 7/1, 7/6, 7/13, 7/15 and 7/19/2021, were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. 7. Patient #6 had a start of care date of 10/31/2016. Clinical record review revealed the following: The Plans of Care, dated 10/16/2020 to 12/14/2020, 12/15/2020 to 2/12/2021, 2/13/2021 to 4/13/2021, 4/14/2021 to 6/12/2021 and 6/13/2021 to 8/11/2021, included orders for skilled nursing services. The skilled nursing visit notes, dated 11/2 and 12/7/2020, 1/4, 2/1, 3/1, 4/5, 5/3, 6/1 and 7/6/2021, were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. 8. Patient #8 had a start of care date of 6/8/2021 and was discharged from services on 7/6/2021. Clinical record review revealed the following: The Plan of Care, dated 6/8/2021 to 8/6/2021, included orders for skilled nursing services. a. The initial comprehensive assessment completed at admission to home health services, dated 6/8/2021, was hand signed by the RN and dated; however, lacked a time of signature. b. The skilled nursing visit notes, dated 6/8, 6/9, 6/10, 6/11, 6/15, 6/16, 6/21 and 6/23/2021, were hand signed by the RN completing the visit. The notes included the date of the visit, time of initiation of the visit and time the visit ended; however, lacked a date and time of the nurse's signature signifying completion of the documentation of the visit. c. The Nursing Progress Notes, dated 6/14, 6/22, 6/24, 6/25, 6/28, 6/30, 7/2 and 7/6/2021, documented attempts to see the patient with an inability to either contact the patient or the patient failed to present for a planned visit. Each Progress Note included the date of attempted contact and time of contact and was signed by the RN; however, lacked a date and time of the nurse's signature signifying completion of the documentation. The above stated findings for Patients #1, #2, #3, #4, #5, #6, #8 and #10 were reviewed with the Administrator. The agency provided no additional information prior to the end of the survey.