Des Moines County Health Department

“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 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 2 of 7 sampled patients. (Patients #2 and #6) 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 – CMS #485 and Physician/ Practitioners Orders, dated February 2025, if the agency provides fewer visits than the physician/ practitioner orders, it has altered the plan of care and the physician/ practitioner must be notified. The agency must maintain documentation in the clinical record indicating that the physician/ practitioner was notified and is aware of the missed visit. During an interview on 1/8/26 at 10:37 AM, Administrator reported communication with physicians is documented in an electronic physician notification, printed out and faxed to the physician. 1. Patient #6 had a start of care date of 11/7/24 and a discharge date of 12/31/25. Clinical record review revealed: a. Plan of Care, dated 11/2/25 to 12/31/25, included primary diagnosis of end-stage renal disease and physician orders for skilled nursing and home health aide services. b. Home health aide documentation, dated 11/20/25, identified the patient refused services. c. Interim physician order, dated 11/20/25, included documentation of a missed home health aide visit on 11/20/25, a handwritten signature and dated 1/21/26. During an interview on 1/22/26 at 9:00 AM, Staff B, Clinical Manager, reported she was unable to locate an interim physician order for the missed visit on 11/20/25, Staff C, RN (registered nurse) wrote an order and faxed to physician office on 1/21/26. 2. Patient #2 had a start of care date of 3/5/25. Clinical record review revealed: a. Plan of Care, dated 11/1/25 to 12/30/25, included primary diagnosis of chronic obstructive pulmonary disease and physician orders for skilled nursing and home health aide services 2 times a week. b. Home health aide documentation, dated 12/26/25, identified the patient refused services. c. Interim physician order, dated 12/23/25, included documentation of a missed home health aide visit on 12/23/25, a handwritten signature and dated 1/21/26. During an interview on 1/22/26 at 9:00 AM, Staff B, Clinical Manager, reported she was unable to locate an interim physician order for the missed visit on 12/23/25, Staff C, RN wrote an order and faxed to physician office on 1/21/26. The above findings were reviewed with Staff A, Administrator, and Staff B, Clinical Manager.”

“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 obtain physician orders for resumption of care services for 2 of 2 sampled patients (Patients #1 and #5) with resumption of care assessments. Failure to ensure staff obtain physician orders for all services and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care – CMS #485 and Physician/ Practitioners Orders, dated February 2025, drugs, services and treatments are administered by staff as ordered by physician/ practitioner. Verbal orders are put in writing, signed, timed and dated with the date of receipt by skilled nurse responsible for furnishing or supervising ordered services. All clinical services are implemented only in accordance with a Plan of Care established by a physician/ practitioner’s written order. 1. Patient #1 had a start of care date of 4/27/17. Clinical record review revealed: a. Plan of Care, dated 9/12/25 to 11/10/25, included primary diagnosis of major depressive disorder and physician orders for skilled nurse and home health aide services. b. Resumption of care assessment, dated 9/16/25, completed. c. Interim physician order, dated 9/16/25, for resumption of home care services identified a handwritten signature, dated 1/22/26. During an interview on 1/22/26 at 11:00 AM, Staff B, Clinical Manager, reported she was unable to find the resumption of care order for 9/16/25. The agency failed to obtain interim physician order for resumption of care at the time resumption of care assessment was completed. 2. Patient #5 had a start of care date of 3/16/17. Clinical record review revealed: a. Plan of Care, dated 9/30/25 to 11/28/25, included primary diagnosis of neuroleptic induced parkinsonism and physician orders for skilled nurse and home health aide services. b. Resumption of care assessment, dated 11/6/25, completed. c. Interim physician order, dated 11/6/25, for resumption of home care services identified a handwritten signature, dated 1/21/26. During an interview on 1/22/26 at 9:00 AM, Staff B, Clinical Manager, reported she was unable to find the resumption of care order for 11/6/25. The agency failed to obtain interim physician order for resumption of care at the time resumption of care assessment was completed. The above findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.”

“HH aide supervision elements CFR(s): 484.80(h)(4)(i-vi) Home health aide supervision must ensure that aides furnish care in a safe and effective manner, including, but not limited to, the following elements: (i) Following the patient’s plan of care for completion of tasks assigned to a home health aide by the registered nurse or other appropriate skilled professional; (ii) Maintaining an open communication process with the patient, representative (if any), caregivers, and family; (iii) Demonstrating competency with assigned tasks; (iv) Complying with infection prevention and control policies and procedures; (v) Reporting changes in the patient’s condition; and (vi) Honoring patient rights. This Element is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure registered nurses supervising home health aides maintained documentation of a review of all required supervisory elements including following the patient plan of care, maintaining open communication with patient/caregiver, demonstrating competency of all assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition and honoring patient rights for 4 of 5 sampled patients receiving home health aide services that required aide supervision (Patients #1, #2, #3 and #5). Failure to ensure the supervision of home health aides by registered nurses maintained documentation of a review of all required supervisory elements increased the risk of agency staff not meeting the patients’ personal care needs. Findings include: According to the agency policy titled, Home Health Aide Supervision, dated February 2024, hoe health aide supervision must ensure that aides furnish care in a safe and effective manner, including but not limited to, the following elements: following the patient’s plan of care, maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies and procedures, reporting changes in the patient’s condition, and honoring patient rights. During an interview on 1/21/26 at 3:00 PM, Staff B, Clinical Manager, reported some aide supervision may be handwritten on a nurses note document verses the visit note document but voiced understanding of what elements were missing. 1. Patient #1 had a start of care date of 4/27/17. Clinical record review revealed: a. Plan of Care, dated 11/11/25 to 1/9/26, included primary diagnosis of major depressive disorder and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit notes, dated 11/25/25, 12/2/25, 12/9/25, 12/23/25, 12/30/25 and 1/13/26, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. 2. Patient #2 had a start of care date of 3/5/25. Clinical record review revealed: a. Plan of Care, dated 11/1/25 to 12/30/25 and 12/31/25 to 2/28/26, included primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit notes, dated 11/26/25, 12/3/25, 12/10/25, 12/22/25, 12/31/25 and 1/14/26, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. 3. Patient #3 had a start of care date of 2/9/23. Clinical record review revealed: a. Plan of Care, dated 11/25/25 to 1/23/26, included primary diagnosis of Type 2 Diabetes Mellitus without complications and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit note, dated 12/22/25, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. 4. Patient #5 had a start of care date of 3/16/17. Clinical record review revealed: a. Plan of Care, dated 11/29/25 to 1/27/26, included primary diagnosis of neuroleptic induced parkinsonism and physician orders for skilled nurse and home health aide services. b. Skilled nursing visit notes, dated 12/3/25, 12/17/25, 12/31/25 and 1/14/26, included home health aide supervision aide following care plan marked as yes. The supervision failed to include the elements maintaining open communication, demonstrating competency with assigned tasks, complying with infection prevention and control policies, reporting changes in the patient condition, and honoring patient rights. The registered nurse failed to document to all required elements of home health aide supervision as regulated. The above findings were reviewed with Staff A, Administrator and Staff B, Clinical Manager.”