Iowa County Health Department

“Duties of a HH aide CFR(s): 484.80(g)(3) The duties of a home health aide include: (i) The provision of hands-on personal care; (ii) The performance of simple procedures as an extension of therapy or nursing services; (iii) Assistance in ambulation or exercises; and (iv) Assistance in administering medications ordinarily self-administered. This Element is not met as evidenced by: Based on agency policy review, clinical record review, staff and patient 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 1 of 5 sampled patients receiving home health aide services (Patient #5). 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 include: According to the agency policy titled Home Health Aide Services, dated 3/20/24, home health aide services will be provided to appropriate clients on an intermittent, part-time or full-time basis, under the direct supervision of an agency Registered Nurse in accordance with a medically approved plan of care. According to the agency policy titled Home Health Aide Care Plan, dated 3/20/24, prior to initiating care, the home health aide shall be oriented by a Registered Nurse, by phone or in person, to the client’s care needs and shall be updated on modifications or changes in the client’s care. On-sit orientation and return demonstration of skills will be done as determined by client/caregiver request, client needs, or assessment of the nurse. If the home health aide is assigned to provide advanced skills, the home health aide must be oriented to the procedure by a Registered Nurse who documents evidence of competency. The home health aide cannot be responsible for performing any procedure that is not assigned to them in writing by the Registered Nurse or that is beyond their ability. The Home Health Aide tasks must be related to the physical care needs of the client. According to the agency policy, titled Home Heath Aide Competency, dated 3/20/24, a home health aide will not be permitted to provide home health aide services until evidence of adequate training and/or competence has been determined by their individual supervisor. The home health aide must demonstrate evidence of successful completion of a competency evaluation program for any tasks the agency may choose to have home health aide perform as permitted under Iowa law and providing there is evidence of home health aide orientation to and competency in the delegated task. Patient #5 had a start of care date of 11/25/24. Clinical record review revealed the following: 1.The plans of care (POCs), dated 11.25.24 to 1.23.25 and 1.24.25 to 3/24/25, identified the patient had diagnoses that included chronic respiratory failure with hypoxia, shortness of breath, tachycardia and unspecified dementia. The POCs included orders for skilled nurse services 1 time every other week and home health aide (HHA) services 1 time a week. The POCs included physician orders for the HHA to remined the patient to increase oxygen to 4 liters when walking. 2. The home health aide care plan, dated 12/2/24, Staff G, Registered Nurse (RN) included the assigned home health aide task to increase oxygen to 4 liters with ambulation and decrease oxygen to 3 liters when sitting. 3. The home health aide notes, dated 12/26/24, 1/2/25, and 1/9/25, included documentation Staff F, HHA completed the assigned tasks. 4. Review of Staff F, HHA’s employee file identified a hire date of 5/26/22. The Home health aide training dated 5/17/24, included procedures that the HHA cannot perform including in part: adjust oxygen rate. The employee file lacked documentation of Staff F competency to adjust oxygen rate. During an interview on 2/20/25 at 4:30 PM, the Administrator stated when she and the Clinical Manger had knowledge that Staff G, RN added the HHA task to adjust the patient’s oxygen rate of flow, they instructed Staff G RN to remove the task from the HHA care plan. She further stated it is the agencies policy to not allow HHA to preform adjustments of a patient’s oxygen rate of flow. The agency nurse failed to ensure assigned HHA task permitted under state law. The above findings reviewed with the Administrator and Clinical Manager.”

“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 for 3 of 7 sampled patients with wounds. (Patient #1, #6 and #7) 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. 3. Patient #6 had a start of care date of 2/2/24. Clinical record review revealed the following: a. The POC, dated 2/2/24 to 4/1/24 included physician orders for skilled nurse to monitor skin and surgical wound. b. Skilled nurse visit notes, dated 2/21/24 and 2/28/24, completed by Staff B, Registered Nurse (RN), noted the appearance of the surgical wound but lacked measurements of the wound. Skilled nurse failed to measure the surgical wound. The above findings were reviewed with the Administrator, Clinical Manager, and Staff C, Registered Nurse. 2. Patient # 1 had a start of care date of 6/24/21. During a home visit observation on 9/10/24 at 11:00 am, Staff C, Registered Nurse, (RN) observed and noted a new wound on the coccyx of patient #1. The RN cleansed the area and placed a foam dressing over the area and stated to patient #1 she would notify the physician of the new wound area following the home visit. The RN did not obtain any measurements of the new wound when assessing the area. During an interview with Staff C, on 9/11/24 at 8:30 AM, stated she has measured enough wounds, she can just approximate the size without using any type of measuring device. Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/7/24 to 10/5/24 included physicians orders for skilled nurse to monitor skin once a week and provide wound care when needed. b. The nurses note, dated 8/12/24, included documentation of a new open area near the patient’s rectum that included measurements of length and width, but lacked documentation for the depth of the wound. c. The nurses note dated 8/27/24, included documentation for the established wound and included measurements for length and width, but lacked documentation of the depth. Two new additional wounds to the gluteal area were identified, but only one set of measurements was documented, and lacked documentation specific to each wound assessed. The nurse failed to obtain measurements of a new wound, and failed to measure the depth of an established wound weekly. Findings: According to the agency policy, titled Wound Care, dated 12/14/23, measurements of wound shall be performed by a registered nurse, will include length, width and depth, and will occur at a minimum weekly. During an interview on 9/10/24 at 8:52 AM, Clinical Manager reported wound measurements are completed weekly and include length, width and depth. 1. Patient #7 had a start of care date of 4/25/23 and a discharge date of 4/30/24. Clinical record review revealed: a. Interim physician order, dated 3/20/24, included orders for skilled nursing to start zinc oxide topical ointment, apply thin layer to buttocks as needed for open areas. b. Comprehensive assessment completed at time of Resumption of Care, dated 3/20/24, included documentation the patient had 2 open areas, 1 cm (centimeter) by 2 cm, on the right side of buttocks, spouse is using barrier cream. Skilled nurse failed to identify a wound depth for the 2 open areas on buttocks.”

“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 staff interview, clinical record reviews and policy review, the hospice failed to ensure all entries were complete and appropriately authenticated with a signature, title, date and time for 5 of 7 sampled patients (Patients #1, #2, #4, #6 and #7). Failure to maintain timely, accurate and 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: 5. Patient #7 had a start of care date of 4/25/23 and a discharge date of 4/30/24. Clinical record review revealed: a. Comprehensive assessment completed at Start of Care, dated 4/25/23, included an electronic signature with nurse name, date and time, but lacked a discipline title. b. Comprehensive assessment completed at Recertifications of Care, dated 12/18/23, 2/15/24 and 4/17/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. c. Comprehensive assessment completed at Resumption of Care, dated 3/20/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. d. Comprehensive assessment completed at Discharge from Care, dated 4/30/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. e. Skilled nurse visit note, dated 4/26/24, lacked documentation of an electronic signature. During an interview on 9/10/24 at 1:48 PM, Clinical Manager reviewed the electronic record and confirmed the skilled nurse visit note, dated 4/26/24, had not been marked as completed with an electronic signature. The agency provided no additional information prior to the end of the survey. 3. Patient #2 had a start of care date of 3/4/24. Clinical record review revealed: a. The comprehensive assessment completed at Recertification of Care, dated 8/27/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. b. The skilled nurse visit notes, dated 7/10, 7/16, 7/22, 7/30/24, 8/6, 8/13, 8/19, 8/17/24 and 9/4/14, lacked documentation of an electronic signature. 4. Patient #4 had a start of care date of 8/26/24. Clinical record review revealed: a. The comprehensive assessment completed at Start of Care, dated 8/26/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. 2. Patient #1 had a start of care date of 6/4/21. Clinical record review revealed the following: a. Comprehensive assessment completed at Recertifications of Care, dated 4/5/24, 6/4/24 and 8/6/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. b. Comprehensive assessment completed at Resumption of Care, dated 4/18/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. c. Skilled nurse visit notes dated, 7/8/24, 7/15/24, 7/22/24, 7/29/24, 8/12/24, 8/27/24, 8/29/24 and 9/3/24, included an electronic signature with nurse name, date and time, but lacked a discipline title. According to the agency policy titled Clinical Documentation, dated 7/17/24, all skilled services provided by nursing or therapy will be documented in the clinical record. A separate note shall be completed for each visit and signed and dated by the appropriate professional within 72 hours of the day service is rendered. 1.Patient #6 had a start of care date of 2/2/24 and a discharge date of 3/15/24. Clinical record review revealed: a. The initial comprehensive assessment dated 2/2/24, completed by Staff C, Registered Nurse (RN), included an electronic signature with a nurse name, date and time, but lacked a discipline title. b. The skilled nurse visit notes, dated 2/5/24, 2/8/24, 2/12/24, 2/16/24 and 2/28/24, completed by Staff C, RN, included an electronic signature with a nurse name, date and time but lacked a discipline title. c. The comprehensive assessment completed at discharge from care, dated 3/15/24, completed by Staff C, RN, included an electronic signature with a nurse name, date and time but lacked a discipline title.”

“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 agency staff interview and clinical record review, the agency failed to follow physician orders for medication set up and foley catheter placement for 2 of 7 sampled patients (Patient’s #3 and #4). Failure to ensure staff obtain and follow physician orders for administration of medications and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 2. Patient #4 had a start of care date of 8/26/24. Review of the clinical record revealed the following: a. The POC, dated 8/26/24 to 10/24/24, included orders for catheter changes via sterile technique 1 time a month. The POC lacked orders to include the size of the catheter and balloon. b. The comprehensive assessment at admission, dated 8/26/24, included documentation the patient required a Foley catheter 16 French, with 10 milliliter balloon to straight drainage. The agency failed to include physician orders for size of catheter. The above findings shared with the Director, Clinical Manager and Staff C, RN. 1.Patient #3 had a start of care date of 6/21/24. Review of the clinical record revealed the following: a. The Plans of Care (POCs), dated 6/21/24 to 8/19/24 and 8/20/24 to 10/18/24 documented the patient had orders for skilled nurse visits every other week to set up medications in a medication planner per patient request. The orders included the medication Verapamil Hydrochloride 120 milligrams (mg) with instructions to take one tablet two times a day to treat high blood pressure. b. During a home visit observation with Staff B, Registered Nurse (RN) on 9/9/24 at 2:30 PM, the surveyor identified Staff B missed putting a dose of Verapamil Hydrocholoride in the patient’s medication planner. An interview with Staff B during this visit confirmed she had missed putting a dose of Verapamil Hydrochloride in an evening slot and corrected the mistake. The RN failed to follow physician orders when setting up the patient’s medications. Findings include: According to the agency policy, titled Plan of Care – 485, dated 7/17/24, identified an individualized Plan of Care shall include medications, treatments, procedures, medical supplies and equipment required.”