Sioux Center Home Health and Hospice

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness to all existing staff, including staff employed under arrangement of contract, consistent with their expected roles. Lack of emergency preparedness training for all staff placed patients at risk for inadequate assistance should an emergency situation arise and staff would be needed to assist patients to ensure patients safety. Findings include: During agency staff interview on 11/21/23 at 1:49 PM the Administrator stated aa contracted staff trained by there primary employment for the emergency policy but not specific to the home health agency policy. Review of the agency staff Emergency Preparedness policy, dated 6/2023, all of the contracted therapy staff had not received training for the agency emergency preparedness plan. The agency did not ensure initial and annual training for the agency’s emergency preparedness/disaster plan to ensure each employee’s understanding of the plan was completed The above stated findings were reviewed with the Administrator and Staff B, Registered Nurse. The agency provided no further information prior to the end of the survey.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on clinical record review, agency policy review and staff interview, the agency failed to ensure agency staff advised the patient of the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care for 6 of 7 sampled patients (Patients #1, #2, #3, #4, #6, and #7). At the time of the survey, the agency reported a current census of 24 patients. Failure to ensure agency staff advised the patient the extent to which payment for agency services may be expected and the charges for services that may not be covered from Medicare, Medicaid, or any other federally-funded or federal aide program known to the agency and the charges the individual may have to pay before the agency initiated care placed agency patients at risk for the patient’s rights being violated and the patient being unexpectedly charged for services. 3. Patient #1 had a start of care date of 10/24/23. The POC, dated 10/24/23 to 12/22/23, included physician orders for skilled nursing, physical therapy and home care aide services. The Admission Consent form, dated 10/24/23, included documentation the patient had received a copy of the patient’s rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through Medicare, but failed to identify the charges for services that may not be covered by insurance. 4. Patient #3 had a start of care date of 11/8/23. The POC, dated 11/8/23 to 1/6/24, included physician orders for skilled nursing and physical therapy services. The Admission Consent form, dated 11/8/23, included documentation the patient had received a copy of the patient’s rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through Medicare, but failed to identify the charges for services that may not be covered by insurance. 5. Patient #4 had a start of care date of 11/7/23. The POC, dated 11/7/23 to 1/5/24, included physician orders for skilled nursing and physical therapy services. The Admission Consent form, dated 11/7/23, included documentation the patient had received a copy of the patient’s rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through Private Insurance, but failed to identify the charges for services that may not be covered by insurance. 6. Patient #6 had a start of care date of 7/6/23. The POC, dated 7/6/23 to 9/2/23 and 9/3/23 to 11/2/23, included physician orders for skilled nursing, physical therapy and home care aide services. The Admission Consent form, dated 7/6/23, included documentation the patient had received a copy of the patient’s rights. The Admission Consent form included a financial responsibility section which identified the agency planned to bill services through Medicare, but failed to identify the charges for services that may not be covered by insurance. The above findings review with the Administrator and Staff B, Registered Nurse. The agency failed to provide further information prior to the end of the survey. Findings include: In an interview on 11/21/23 at 3:00 PM, the Administrator reported the agency does not have a policy related to how the consent form should be completed. The Administrator was in agreement when she was made aware of the issue by shaking her head vertically. 1. Patient #2 had a start of care date of 11/6/23. Home visit observation on 11/21/23 at 8:30 AM and clinical record review revealed a consent form located in the patient’s home had checkmarks in the spaces in which the cost for home health services was expected to be listed. The patient’s clinical record included a written consent form, which the agency titled Home Care Services Agreement Exhibit C, signed by the patient and dated 7/20/18 (a previous episode of care provided to Patient #5). The document included both Medicare and Medicaid as potential payers but failed to include identification of which federally funded program would be payer for home health services or how much the patient could expect to pay out of pocket for services. 2. Patient #7 had a start of care date of 1/28/123and received services from the agency. Clinical record review revealed a written consent form, which the agency titled Home Care Services Agreement Exhibit C, signed by the patient and dated 7/20/18 (a previous episode of care provided to Patient #5). The document included both Medicare and Medicaid as potential payers but failed to include identification of which federally funded program would be payer for home health services or how much the patient could expect to pay out of pocket for services.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on facility records, agency policy review, patient interview, and staff interview, the agency failed to provide contact information for the state agency, Department of Inspections, Appeals, and Licensing (DIAL), complaint department on admission to home health services for 5 of 7 sampled patients (Patients #1, #2, #3, #4 and #6). At the time of the survey, the agency reported a current census of 24 patients. Failure to provide contact information to file a complaint with DIAL for patients to call for assistance in resolving a complaint with the agency possibly denied patients of their rights to file a complaint outside of the home health agency. 1. Patient #1 had a start of care date of 10/24/23. The POC, dated 10/24/23 to 12/22/23, included orders for skilled nursing, physical therapy and home care Aide services. The Admission Consent Form, dated 10/24/23, identified the patient received a copy of the bill of rights. The Patient Bill of Rights failed to include the State Hotline number to make a complaint of the home health agency. 2. Patient #2 had a start of care date of 11/2/23. The POC, dated 11/2/23 to 1/4/24, included orders for skilled nursing and physical therapy services. The Admission Consent Form, dated 11/2/23, identified the patient received a copy of the bill of rights. In an observation and interview on 11/21/23 at 8:30 AM, when asked if the patient knew how to contact the State toll-free hotline to file a complaint, the patient reported that she expected to find the information in her admission folder. Further observation of the admission folder revealed that the contact information for State toll-free hotline was not located in the admission folder The Patient Bill of Rights failed to include the State Hotline number to make a complaint of the home health agency. 3. Patient #3 had a start of care date of 11/8/23. The POC, dated 11/8/23 to 1/6/24, included orders for skilled nursing and physical therapy services. The Admission Consent Form, dated 11/8/23, identified the patient received a copy of the bill of rights. The Patient Bill of Rights failed to include the State Hotline number to make a complaint of the home health agency. 4. Patient #4 had a start of care date of 11/7/23. The POC, dated 11/7/23 to 1/5/24, included orders for skilled nursing and physical therapy services. The Admission Consent Form, dated 11/7/23, identified the patient received a copy of the bill of rights. The Patient Bill of Rights failed to include the State Hotline number to make a complaint of the home health agency. 5. Patient #6 had a start of care date of 7/6/23 and discharge date of 9/11/23. The POC, dated 7/6/23 to 9/2/23 and 9/3/23 to 11/2/23, included orders for skilled nursing, physical therapy and occupational therapy services. The Admission Consent Form, dated 7/6/23, identified the patient received a copy of the bill of rights. The Patient Bill of Rights failed to include the State Hotline number to make a complaint of the home health agency. The above findings shared with the Administrator and Staff B, RN. No additional information provided prior to the end of the survey. Findings include: Review of the Patient Bill of Rights, undated, revealed in pertinent part: Use of the toll-free hotline established by the department to receive complaints or questions about local agencies and hours of operation of the hotlines as; with a phone number listed. When the toll-free phone number was called, a business not associated with either DIAL or the home health agency answered the call. In a concurrent facility document review and interview on 11/21/23 at 3:00 PM, Staff B, Registered Nurse (RN) asked if the phone number for the DIAL complaint unit had a history of changing and that she did not know which department was specified in the section of the Patient Bill of Rights that was reviewed. The Administrator reported that the agency does not have a policy related to this issue.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on clinical record, agency policy, and staff interview, the agency failed to ensure clinicians followed agency policies and procedures when assessing wounds to agency patients for 2 of 4 sampled patients with wounds (Patient #1 and #4). Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. Findings include: According to agency policy titled, Wound Care, last revised 2/2019, documentation of wound should be completed as follows: anatomical location, appearance of wound, wound size, measurements will be completed weekly and as needed including length, width and depth. 1. Patient # 1 had a start of care date of 10/24/23. Clinical record review revealed the following: a. The admission comprehensive assessment, dated 10/24/23, included documentation the patient had an upper midline wound that measured 3 cm by 0.7 cm but lacked documentation of measurement of the wound depth. The clinical record lacked documentation of complete wound measurements with the comprehensive assessment. 2. Patient # 4 had a start of care date of 11/7/23. Clinical record review revealed the following: a. The admission comprehensive assessment, dated 11/7/23, included documentation the patient had a lower back left drain wound that measured 3 centimeters (cm) by 0.7 cm by 0.1 cm. The patient also had a surgical wound on the lower midline back that measured 16 cm by 0.1 cm by 0 cm and an abdominal midline surgical incision that measured 17.5 cm by 0 by o cm. b. The skilled nurse visit notes, dated 11/14/23 and 11/16/23, failed to include documentation of wound measurements. The agency failed to document wound measurements with week of 11/12/23 through 11/18/23. The clinical record lacked documentation of complete wound measurements with the comprehensive assessment. The above findings shared with the Administrator and Staff B, RN. The agency provided no further information prior to the end of the survey.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to complete a drug regimen review within the required time frames as part of the update to the comprehensive assessment at discharge for 2 of 2 sampled patients requiring discharge from agency services (Patients #6 and #7). The agency reported a current patient census of 24 patients. 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. 2. Patient #6 had a start of care date of 7/6/23 and was discharged from agency services on 9/11/23. The Plan of Care, dated 7/6/23 to 9/2/23 and 9/3/23 to 11/2/23, included orders for the patients medications. The skilled nurse visit note, dated 9/11/12, lacked documentation of a completed drug regimen review. Review of the discharge summary, dated 9/11/23, lacked documentation of a completed drug regimen review. Clinical record review lacked documentation of a completion of the required drug regimen review at the time of agency discharge. The Administrator and Staff B, Registered nurse received the above findings. The agency did not provide additional information prior to the end of the survey. Findings Include: Agency policy, titled Drug Regimen Review dated 9/23, directed the following in pertinent part: A comprehensive assessment of medications will be done by a RN (Registered Nurse) will be done on admission and with each comprehensive assessment. Drug regime review will be conducted on discharge. In an interview on 11/21/23 at 3:00 PM, the Administrator/Clinical Manager reported that clinicians are expected to assess all medications at the time of discharge. 1. Patient #7 had a start of care date of 1/28/23 and was discharged from agency services on 3/1/23. Clinical record review lacked documentation of a completion of the required drug regimen review at the time of agency discharge.”

“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 staff interview, the agency failed to ensure accurate completion of the recertification comprehensive assessments between day 56 and 60 of each 60 day certification period for 1 of 2 sampled patients for recertification requiring a recertification assessment (Patient #5). The agency reported a census of 24 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: The agency policy, titled Non-OASIS Patient Comprehensive Assessment Policy dated 5/23, revealed in pertinent part that the comprehensive assessment will be updated and revised the last 5 days of every 60 day period beginning from the start of care date. Patient #5 had a start of care date of 5/12/20 and received services from the agency. Clinical record revealed: An update to the comprehensive assessment for recertification, dated 10/11/23. The last day of the patient’s 60 day certification period was 10/23/23. The agency failed to update the comprehensive assessment in the last 5 days of the 60 day episode. The above findings were reviewed with the agency Administrator/Clinical Manager. 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 observation, clinical record, agency policy, patient interview, and staff interview, the agency failed to include all Durable Medical Equipment (DME) in Plans of Care for 3 of 7 sampled patients (Patients #2, #6, and #7). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. 3. Patient #6 had a start of care date of 7/6/23 and discharge date of 9/11/23. Clinical record review revealed: a. The POCs, dated 7/6/23 to 9/2/23 and 9/3/23 to 11/2/23, included the following durable medical supplies utilized by the patient: walker, shower chair, hallway railings, grab bars-toilet-stairs and shower tub and bed rails. b. The skilled nurse note on 7/11/23 revealed the patient’s family sets up the patient’s medications in daily planners. The note also identified the patient utilized colostomy supplies. The Plan of Care dated lacked medication and colostomy supplies listed as DME. The above findings shared with the Administrator and Staff B, RN. No additional information provided prior to the end of the survey. Findings include: Agency policy, titled Care Planning dated 4/2023 revealed in pertinent part that the Plan of Care will include equipment. 1. Patient #2 had a start of care date of 1/28/23 and received services from the agency. In a concurrent observation and interview with the patient on 11/21/23 at 8:30 AM, the patient reported to Staff C, Registered Nurse (RN) that she had compression hose applied in the hospital and wore them during her home health admission assessment. The patient then had difficulty putting them on in the home. When the Occupational Therapist (OT) visited her at home, she received instruction on how to apply the compression hose and wore them for 1 day until the swelling in her leg subsided and she no longer needed them. The Plan of Care signed by a physician on 11/10/23 lacked compression hose listed as DME. 2. Patient #7 had a start of care date of 11/6/23 and received services from the agency. Clinical record review revealed: a. Skilled nurse note on 2/21/23 revealed the patient wore compression stockings during the visit. b. Skilled nurse note on 2/6/23 revealed that the nurse performing the visit put compression hose on the patient during the visit. c. Plan of Care dated lacked compression hose listed as DME.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on clinical record, agency policy, and staff interview, the facility failed to obtain orders for nursing procedures for 3 of 7 patient reviewed (Patients #3, #4, and #5). Failure to maintain complete and accurate Plans of Care (POC) with current orders placed the patients at risk to not receive services, medication and/or treatments according to assessed needs and physician orders. 2. Patient #3 had a start of care date of 11/8/23 and received services from the agency. a. The Plan of Care for the certification period from 11/8/23 to 1/6/24 included orders for a Foley catheter. b. The physician’s order, dated 11/9/23, included the order, OK to flush (foley catheter) as needed. c. The skilled nurse visit note, dated 11/10/23, documented the skilled nurse flushed the foley catheter with sodium chloride and 60 cubic centimeters (cc) syringe. Flushed easily (120 cc’s) with 350 cc returned of amber urine with minimal red flecks. The clinical record lacked a clarification orders for specific information including solution, amount and frequency to the order to flush the Foley catheter. 3. Patient #4 had a start of care date of 11/7/23 and received services from the agency. a. The Plan of Care for the certification period from 11/7/23 to 1/5/24 included orders for medication milk of magnesia (laxative). b. The skilled nurse visit note, dated 11/14/23, documented the skilled nurse visited with the patient about constipation. The patient had Miralax in the home and will start to alternate with Milk of Magnesia. The clinical record lacked a clarification order for the medication Miralax. The above findings shared with the Administrator and Staff B, RN. The agency provided no further information prior to the end of the survey. Findings include: The agency’s Comprehensive Policy dated 1/23, in pertinent part, directed that written orders are required for physical therapy, selected rehabilitation, nursing procedures, medications, and all services. In an interview on 11/21/23 at 3:00 PM, Staff B, Registered Nurse (RN) reported that she has always written per protocol in orders instead of specific information related to the order. 1. Patient #5 had a start of care date of 5/12/20 and received services from the agency. Clinical record review revealed an order on the Plan of Care for the certification period from 10/24/23 to 12/22/23 as follows: please flush the patient’s port as needed/requested by patient per protocol to maintain patency. The clinical record lacked an additional order for specific information related to the order listed on the POC.”