Webster County Health Department

“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: According to the policy, titled Policy for Electronic Signature/Authentication, dated Feb. 2026, routine or on-call visits will need to be completed and e-signed within 72 hours of the assessment with expectations to be completed within 24 hours. During an interview on 2/11/26 at the Home Care Aide Coordinator stated the agency Aides only document in the State application for billing. The record does not incclude the staff electronic signature. 1.Patient #1 had a start of care date of 12/4/2020. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/8/25 to 1/6/26 and 1/7/26 to 3/7/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The home health aide visit notes, dated 1/27, 1/30/26, 2/3 and 2/6/26, completed by Staff E, Home Care Aide (HCA), failed to include Staff E’s electronic signature to include the discipline. The agency failed to staff electronic signature and discipline. 2. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed the following: a. The POC, dated 11/25/25 to 1/23/26 and 1/24/26 to 3/24/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The home health aide visit notes, dated 1/27, 1/30/26, 2/3 and 2/5/26, completed by Staff E, HCA, failed to include Staff E’s electronic signature to include the discipline. The agency failed to include staff electronic signature and discipline. 3. Patient #7 had a start of care date of 5/27/25 and discharge date of 7/3/25. Clinical record review revealed the following: a. The POC, dated 5/7/25 to 7/3/25, included primary diagnosis of Diabetes Mellitus and physician orders for skilled nurse and home health aide services. b. The home health aide visit notes, dated 5/25/25, 6/1 and 6/2/25, completed by Staff E, HCA, failed to include Staff E’s electronic signature to include the discipline. The agency failed to include staff electronic signature and discipline. The above stated findings were reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to provide an initial assessment visit within 48 hours of receipt of referral for 1 of 6 sampled patients with admissions since last survey (Patient #3). Failure to provide an initial assessment visit within 48 hours put agency patients at risk for not having immediate care needs met. Findings include: The agency policy, Initial and Comprehensive Assessment Policy, dated Feb. 2026, a Registered Nurse must conduct the initial assessment visit to determine the immediate care and support needs of the client. They must also determine eligibility for the Medicare Home Health benefit and homebound status. The initial assessment must be held within 48 hours of referral or within 48 hours of the clients’ return home or on the physician ordered start of care date. Patient #3 had a start of care date of 9/26/25 and received services from the agency. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/26/25 to 11/24/25, identified the patient had a start of care dated of 9/26/25 and had a diagnosis of Chronic Obstructive Pulmonary Disease. The POC included orders for Home health aide services and skilled nurse services for home care aide supervision. b. The initial referral, dated 9/22/25, to the agency per telephone call, for home health aide services but did not identify a specific start of care date. c. The clinical record lacked documentation of any skilled nursing visit prior to 9/26/24 and lacked documentation of any case communication notes or notes in the electronic medical record (EMR) explaining the delay of the start of care. d. The clinical record lacked documentation of any follow up with the referring physician to report the delay in start of care. The clinical record lacked documentation of any physician’s order to delay the home health services greater than 48 hours. The patient was not admitted to service until 4 days after receiving the referral. In an interview on 5/15/24 at 11:00 AM, the Clinical Manager reported the agency does not have a physician order to allow for the admission greater than 48 hours after the referral. The agency failed to initiate home health services within 48 hours of receiving the referral. The above findings reviewed with the Administrator and Home Health Aide Coordinator”

“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 agency staff interviews, clinical record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 1 of 3 sampled patients with home observation visits (Patient #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. Findings include: According to the agency policy, titled Plan of Care Policy and Procedure, dated Feb. 2026, a review of all medications the client is currently using to identify any potential advers effects, and drug reactions, including ineffective drug therapy, side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. During an interview on 2/11/26 at 11:10 AM, the Administrator/Clinical Manager stated the skilled nurse expeted to complete the Drug Regimen Review at the time of each comprehensive assessment including recertivication of home health services. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed: a. Plans of Care, dated 11/25/25 to 1/23/25 and 1/24/26 to 3/24/26, included primary diagnosis of chronic obstructive pulmonary disease (COPD) and physician orders for home health aide services, skilled nurse services for comprehensive assessments and home health aide supervision. The POC included orders for Morphine 15 milligrams (mg) every 6 hours as needed for pain. b. Recertification comprehensive assessment, dated 1/20/26, included documentation of drug regimen review completed. c. During an observation home health visit on 2/10/26 at 10:30 AM with Staff E, Home Care Aide (HCA), the patient stated he/she currently took Hydorocodone/Acetaminophen 10 mg /325 mg every 6 hours as needed for pain. He/She also stated no longer had an order for morphine. The patient identified the change in pain medication occured greater than 2 months ago. The registered nurse failed to complete an accurate drug regimen review at the time of the recertification comprehensive assessment as regulated. The findings were reviewed with the Administrator/Clinical Manager and Home Care Aide Coordinator.”

“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 home observation visits, patient interview, clinical record reviews and agency policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care (POC), including all medical supplies/equipment, all medications, and treatments used by the patient for 2 of 3 sampled patients with observation home visits (Patients #2 and #3). Failure to maintain complete and accurate POCs with current orders placed patients at risk to not receive services, supplies, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Plan of Care Policy and Procedure, Dated Feb. 2026, the required content of the plan of care must include: diagnosis, measureable treatment goals, services required, frequency and duration of visits, specific interventions, medication profile and reconciliation, safety measures, rehabilitation potential, functional limitations, nutritional requirements, activities permitted, patinet/caregiver education needs, emergency preparedness plan and discharge planning. 1.Patient #2 had a start of care date of 1/21/26. Clinical record review revealed: a. The Plan of Care (POC), dated 1/26/26 to 3/26/26, identified the patient had a primary diagnosis of Schizoaffective disorder and included physician orders for medical supplies/equipment used by the patient including: 4 wheeled walker, medicatin planners, cane, glasses, pill cutter, lockbox, lift chair and electric chair. b. During a home observation visit on 2/10/26 at 9:00 AM with Staff D, Registered Nurse (RN), the surveyor identified the patient had a surgical shoe on the left foot. The patient stated the surgical shoe was worn at all times due to an open wound on the left foot caused by a callous. The agency failed to include all medical supplies/equipment on the patient’s POC, including a surgical shoe. 2. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed: a. The POCs, dated 11/25/25 to 1/23/26 and 1/24/26 to 3/24/26, identified the patient had a primary diagnosis of Chronic obstructive pulmonary disease and included physician orders for medical supplies/equipment used by the patient including: cane, 4 wheeled walker with seat, pill cutter, electric scooter, lift chair, glasses, dentures, grab bars, pill cutter and shower chair. b. During a home observation visit on 2/10/26 at 10:30 AM with Staff E, Home Care Aide (HCA), the surveyor identified Staff E assisted the patient with a shower and utilized a hand health shower head. The patient also noted to use an oxygen concentrator and portable oxygen. The agency failed to include all medical supplies/equipment on the patient’s POC, including a hand health shower, oxygen concentrator and portable oxygen. The findings reviewed with the Administrator and Home Health Aide Coordinator.”

“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 clinical record review, policy review and agency staff interview, the agency failed to ensure home health aides provided care to agency patients only as ordered by the physician in the Plan of Care and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 3 sampled patients receiving home health aide services (Patients #1, #3 & #7). The agency reported 5 patients received care provided by a home health aide. Failure to ensure that home health aide services are provided only as ordered by the physician 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 policy, titled Plan of Care, dated Feb. 2026, Home Health Aide Services must be included in the plan of care, based on nursing and therapy assessment. The Home Health Aide supervised and documented at least every 14 days when receiving skilled nursing services and tasks must be specific and measurable. During an interview on 2/11/26 at 11:10 AM, The Administrator/Clinical Manager stated the aide documentation completed on an electronic application that does not allow for tasks to be separated. 1.Patient #1 had a start of care date of 12/4/2020. Clinical record review revealed the following: a. The Plan of Care (POC), dated 11/8/25 to 1/6/26 and 1/7/26 to 3/7/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 1/7/26, identified the following home health aide tasks: assist with shower, assist to shampoo hair and lotion to skin each visit. c. Aide visit notes, dated 1/27/26, 1/30/26, 2/3/26 and 2/6/26, completed by Staff E, Home Care Aide (HCA), included documentation personal care tasks completed (grouped together). The notes failed to identify which tasks were actually completed and if any were not. The agency failed to document on the individual home health aide task to identify each task completed. 2. Patient #3 had a start of care date of 9/26/25. Clinical record review revealed the following: a. The POC, dated 11/25/25 to 1/23/26 and 1/24/26 to 3/24/26, included primary diagnosis of Schizoaffective disorder and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 1/24/26, identified the following home health aide tasks: assist with shower, assist to shampoo hair and lotion to skin each visit. c. Aide visit notes, dated 1/27, 1/30/26, 2/3/26 and 2/5/26, completed by Staff E, HCA, included documentation personal care tasks completed (grouped together). The notes failed to identify which tasks were actually completed and if any were not. The agency failed to document on the individual home health aide task to identify each task completed. 3. Patient #7 had a start of care date of 5/27/25 and discharge date of 7/3/25. Clinical record review revealed the following: a. The POC, dated 5/7/25 to 7/3/25, included primary diagnosis of Diabetes Mellitus and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 5/7/25, identified the following home health aide tasks: apply baza antifungal cream under abdominal and breast folds, assist with shower, assist to shampoo hair, assist dressing and lotion to skin each visit. c. Aide visit notes, dated 5/25/25, 6/1/25 and 6/2/25, completed by Staff E, HCA, included documentation personal care tasks completed (grouped together). The notes failed to identify which tasks were actually completed and if any were not. The agency failed to document on the individual home health aide task to identify each task completed. The above stated findings were reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.”

“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 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 1 of 3 patient receiving home health aide services (Patient #3). 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 policy, titled Plan of Care, dated Feb. 2026, Home Health Aide Services must be included in the plan of care, based on nursing and therapy assessment. The Home Health Aide supervised and documented at least every 14 days when receiving skilled nursing services and tasks must be specific and measurable. In an interview on 2/11/26 at 11:10 AM, the Administrator/Clinical Manager stated the Registered Nurse completes the Home Health Aide supervision evry 14 days and tries to complete weekly to be in compliance. 1.Patient #1 had a start of care date of 12/4/2020. Clinical record revealed the following: a. The Plans of Care dated 11/8/25 to 1/6/26 and 1/7/26 to 3/7/26 included orders for skilled nursing and home health aide services. b. Skilled nursing visit notes, dated 12/23/25, 1/2/26, 1/9/26, 1/16/26, 1/23/26, 1/28/26 and 2/6/26, Staff C, Registered Nurse, documented home health aide supervision completed and the aide reported changes in the patient’s condition. The agency failed to supervise home health aide services to include all required supervisory elements. The above findings reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on observations, agency staff interviews, record review and policy review, the agency failed to send a transfer summary 2 business days of becoming aware of transfer and discharge summary other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 1 patient’s discharged from the agency and transferred to another facility. (Patient #7) Failure to send the physician and other health care professionals a summary of the patient’s care while receiving services from the agency in a timely manner may result in inadequate or inappropriate follow-up during inpatient care or after discharge. Findings include: According to the undated policy, titled Discharge and Transfer Summary Policy and Procedure, dated Feb. 2026, discharge/transfer summaries completed with 48 hours of transfer/discharge. Discharge/Transfer summaries must be submitted to the receiving facility, provider, and/or agency with successful transmission to receiving entity. During an interview on 2/11/26 at 11:10 AM the Administrator/Clinical Manager stated the agency did not send a transfer summary or discharge summary to the receiving agency for patient #7. Patient #7 had a start of care date of 5/27/25 and discharge date of 7/3/25. Clinical record review revealed the following: a. The plan of care, dated 5/27/24 to 7/25/25, identified the patient had a diagnosis of Diabetes Mellitus and included orders for skilled nursing services. b. The comprehensive assessment at discharge, dated 7/3/25, identified the patient discharge from the agency and transfered to another specific home health agency. c. The discharge summary, dated 7/3/25, included the patient discharged from the agency due to admission to another specific agency. The discharge summary sent to the physician. The documentation failed to include a copy of the discharge summary sent to the receiving home health agency. The agency failed to send a copy of the discharge summary to the receiving home health agency. The agency failed to complete the transfer summary and send to the receiving facility within 2 business days of knowledge of the transfer or 5 business days following discharge. The above findings reviewed with the Administrator/Clinical Manager and Home Health Aide Coordinator.”