Carroll Area Nursing Services

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on agency staff interview, agency policy review and review of emergency preparedness testing documentation, the agency failed to ensure participation in emergency preparedness exercises annually included an after action report. Failure to conduct or participate in emergency preparedness exercises placed patients at risk for not having trained and prepared staff to assist them in the event of an emergency. Findings include: According to the agency policy, titled Emergency Preparedness Operating Plan, dated 11/28/23, after each full-scale exercise, tabletop exercise/workshop, mock disaster drill or actual events, the agency will analyze the response, identify areas for improvement and update the emergency preparedness operating plan, if required. Emergency preparedness testing documentation included an actual emergency preparedness exercise, dated 11/30/22, and table top exercise, dated 12/13/23. The agency lacked documentation of an after action report for the exercises. During an interview on 11/6/24 at 9:10 AM, The Administrator stated she could not locate an after action report for the testing. The above findings were reviewed with the Administrator.”

“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 review and policy review, the agency failed to complete an accurate drug regimen review within the required time frame as part of the comprehensive assessment at the time of admission, resumption of care, or discharge from agency services in 3 of 13 sampled patients. (Patient # 1, #2 and #11) 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. 3.Patient #2 had a start of care date of 10/16/24 and received services out of the Manning office. The clinical record review revealed: a. The POC, dated 10/16/24 to 12/14/24, included orders for skilled nursing and physical therapy services and medications. b. The start of care comprehensive assessment, completed by Staff E, Registered Nurse (RN), identified potential adverse effects and drug reactions including significant drug interactions between Warfarin (blood thinner) and Allopurinol (uric acid reducer) and Aspirin (anti-inflammatory and blood thinner) and Tylenol (pain reliever, fever reducer). The agency nurse failed to include documentation of communication to the patient’s physician regarding the significant drug interactions identified. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse. 2. Patient #1 had a start of care date of 10/25/24 and received services out of the Coon Rapids office. a. The POC, dated 10/25/24 to 10/24/24, included orders for skilled nursing and physical therapy services and medications. b. The comprehensive skilled nurse visit note at admission, dated 10/25/24, revealed a DRR completed that included prescription and over the counter medications the patient took. c. During a home observation visit on 11/5/24 at 2:00 PM with Staff C, Clinical Manager, the surveyor observed the patient had the following medications in the home: milk of magnesia, 2 tablespoons every hour of seep as needed for constipation, lidocaine 4% patch to the left shoulder as needed for pain and glucosamine chondroitin triple strength (supplement for bone health) 2 times a day. d. Interview during the same home visit, the patient and patient’s spouse stated the medications had been used “for years”. The agency nurse failed to identify the medications milk of magnesia, lidocaine and glucosamine chondroitin during the DRR. According to agency policy titled Medication Profile, dated April 2018, a drug regimen review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. The review will be performed by qualified personnel and will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative drug therapy, and noncompliance with drug therapy. Interview 11/5/24, at 3:05 PM with Staff Q, Clinical Supervisor, reported the Registered Nurse, (RN) completed the drug regimen review at all assessment time points including admission, resumption of care and discharge. After completion, the RN contacted the physicians with any discrepancies noted. 1.Patient #11 had a start of care date of 5/21/24 and received services out of the Carroll office. The clinical record review revealed: a. Start of Care comprehensive assessment, dated 05/21/24, completed by Staff D, RN, included documentation of noncompliance, duplicate drug therapy, potential drug interactions and ineffective drug therapy, but lacked documentation of specific side effects. The RN failed to complete a drug regimen review that included 1 of the 5 required components, significant side effects.”

“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 visit observations, patient interviews, clinical record reviews and policy review, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient for 4 of 13 sampled patients (Patients #1, #5, #7 and #10). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #1 had a start of care date of 10/25/24 and received services out of the Coon Rapids office. Clinical record review revealed the following: a. The POC, dated 10/25/24 to 12/23/24, included the following DME and supplies used by the patient: probe covers, grab bars, exam gloves, walker, leg brace, diabetic meter and strips, insulin pen needles and lift chair. b. During a home visit observation on 11/4/24 at 2:00 PM, with Staff C, Clinical Manager, the surveyor identified the following DME in the home: TENS (transcutaneous electrical nerve stimulation) unit. The patient and patient’s spouse stated the TENS unity used to the left shoulder as needed for for pain for years. The agency failed to include the TENS unit on the patient’s POC. 3. Patient #7 had a start of care date of 2/15/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The POCs, dated 8/13/24 to 10/11/24 and 10/12/24 to 12/10/24, included the following DME and supplies used by the patient: cane, probe covers, grab bars, exam gloves, tub/shower bench and walker. b. The skilled nurse visit note, dated 8/17/24, identified the patient utilized a medication planner. c. The comprehensive skilled nurse visit note at recertification, dated 10/9/24, identified the patient utilized edema wear and a scale for daily weights. The agency failed to include the medication planner, edema wear and scale used by the patient on the POC. 4. Patient #10 had a start of care date of 11/3/23 and received services out of the Elk Horn office. Clinical record review revealed the following: a. The POC, dated 11/3/23 to 1/1/24 and 1/2/24 to 2/15/24, included the following DME and supplies used by the patient: grab bar and tub/shower. b. The skilled nurse note, dated 1/2/24, identified the patient required wound care and identified wound supplies utilized by the patient. The agency failed to include wound supplies used by the patient on the POC. The above findings shared with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse. According to the agency policy titled Care Planning Process, dated April 2018, the patient Plan of Care (POC) will be developed or revised within five working days of initiation of each service or within 5 working days of the reassessment of the patient. The POC includes but is not limited to: All pertinent diagnoses, all patient care orders including verbal orders, measurable outcomes and goals, functional limitations, medications including dose/frequency/route and supplies and equipment required. 1.Patient #5 had a start of care date of 9/27/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The POC, dated 9/27/24 to 11/25/24, included the following durable medical equipment (DME) and supplies used by the patient: Cane, wheelchair, probe covers, elevated toilet seat, bedside commode, dressing supplies, grab bars, chucks pads, incontinence briefs, medication planner, reacher tool, eye glasses, personal cell phone, compression wraps and lymphedema pumps. b. The initial comprehensive assessment, dated 9/27/24, completed by Staff K, Registered Nurse (RN), identified the patient utilizes a glucometer to monitor blood sugars. c. During a home visit observation on 11/5/24 at 1:00 PM, with Staff K, RN, the surveyor identified the following DME in the home: wheelchair cushions (one to sit on and one to rest back on). During an interview at this same visit, Patient #5 stated he had been utilizing the glucometer for several months and the wheelchair cushions for greater than a year. The POC failed to include the DME of glucometer and wheelchair cushions.”

“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 patient and agency staff interview, home observation visit, clinical record review and agency policy review, the agency failed to update the Plan of Care with all new physician orders for 2 of 8 sampled patients with interim orders. (Patients #3 and #9). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to agency policy, titled Care Planning Process, dated April 2018, the patient-specific clinical plan of care includes all patient care orders including verbal orders. 1.Patient #9 had a start of care date of 5/10/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 9/7/24 to 11/5/24, included physician orders for skilled nursing and home health aide services. b. Interim physician order, dated 10/22/24, included order for skilled nursing services 1-2 times per week for 2 weeks. c. Updated plan of care, printed on 11/5/24, failed to include the skilled nursing frequency order, dated 10/22/24. During an interview on 11/6/24 at 10:20 AM with Staff B, Clinical Manager, confirmed the skilled nurse frequency was missing from the updated plan of care printed on 11/5/24 and was unsure why it did not print. Staff B reported she was unable to reprint an updated plan of care since the new certification period started on 11/6/24. The agency failed to include all interim physician orders in an updated plan of care. 2. Patient# 3 had a start of care date of 8/2/24 and received services out of the Coon Rapids office. Clinical record review revealed the Plans of Care, dated 8/2/24 to 9/30/24 and 10/1/24 to 11/29/24, included physician order for midodrine. During a home observation visit on 11/5/24 at 11:00 AM with Staff S, RN (registered nurse), surveyor reviewed medications with Staff S and patient. Patient and Staff S reported the midodrine had been discontinued about 1 month ago. Staff S instructed surveyor the discontinue order was in electronic medical record with multiple orders on one page and was overlooked. During an interview on 11/6/24 at 10:10 AM with Staff T, Quality Assurance Nurse, she reported physician orders are obtained from the office and then entered on the medication profile, she would review clinical record for discontinue midodrine order. The skilled nurse failed to obtain interim physician order for medication discontinued and update the patient medication list and plan of care. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse.”

“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, home observation visit, clinical record review and agency policy review, the agency failed to provide services and treatments are administered only as ordered by the physician for 2 of 13 sampled patients (Patient’s #3 and #13). Failure to ensure staff obtain physician orders for administration of 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 Clinical/Service Data Collection, dated April 2018, a clinical/service record will be initiated and maintained for each patient receiving care or services according to organization policies and will include physician orders and changes to the plan of care. 1. Patient# 3 had a start of care date of 8/2/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 10/1/24 to 11/29/24, included physician order for skilled nurse to perform skin care to bilateral lower extremities 1-2 times per week as follows: cleanse areas with wound cleanser and gauze, pat dry, cover open areas, weeping sites with a foam bordered dressing until resolved. b. Interim physician order, dated 10/7/24, included skilled nurse to apply Coflex TLC Zinc Lite (or similar) two-layer lite compression wraps (20-30 mmHg) to bilateral lower extremities, cover wraps to bilateral lower extremities with Nylon Stocking, wraps to be changed 1-2 times weekly. During a home observation visit on 11/5/24 at 11:00 AM with Staff S, RN (registered nurse), the surveyor observed Staff S cleanse bilateral lower extremities with gauze and wound cleanser and apply Coflex TLC Zinc Lite two-layer lite compression wraps to bilateral lower extremities. During an interview on 11/5/24 during home observation visit with Staff S, RN, Staff S reported she was unsure if there was an order to cleanse bilateral lower extremities as of 10/7/24 when the treatment changed, she continued to cleanse bilateral lower extremities after the initial order for wound care was obtained. Staff S will check clinical record for physician order to cleanse wounds after visit. Skilled nurse failed to follow physician ordered wound care. 2. Patient #13 had a start of care date of 3/3/23, a discharge date of 10/27/23 and received services out of the Carroll office. Clinical record review revealed: a. Plan of Care, dated 8/30/23 to 10/28/23, included physician order to weigh patient every visit. b. Skilled nurse visit notes, dated 9/21/23 and 10/5/23, failed to include a weight for patient or a reason why weight not obtained. c. Discharge comprehensive assessment, dated 10/27/23, failed to include a weight for patient or a reason why weight not obtained. Skilled nurse failed to obtain a patient weight every visit as ordered by physician. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse.”

“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 staff interviews, clinical record review, and agency policy review, 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 3 of 6 sampled patients receiving home health aide services (Patients #9,#10 and #11). 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. 3. Patient #9 had a start of care date of 5/10/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 9/7/24 to 11/5/24, included physician orders for skilled nursing and home health aide services. b. The home health aide care plans, dated 9/7/24 and 10/22/24, directed the aides to report red/open areas to RN-each visit, provide shower-each visit, shampoo-each visit, sponge bath-per RN request, catheter care-each visit, assist with bilateral knee high edema wear-each visit, and ensure catheter securement device in place and resecure if not-each visit. c. The home health aide visit note, dated 9/20/24, failed to document if the task ensure catheter securement device in place and resecure if not-each visit was completed or a reason why the task was not completed. d. The home health aide visit note, dated 10/25/24, failed to document if the tasks report red/open areas to RN-each visit, provide shower-each visit, shampoo-each visit, sponge bath-per RN request and catheter care-each visit were completed or a reason why the tasks were not completed. e. The home health aide visit note, dated 11/1/24, failed to document if the task assist with bilateral knee high edema wear-each visit was completed or a reason why the task was not completed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse. 2. Patient #10 had a start of care date of 11/3/24 and received services out of the Elk Horn office. Clinical record revealed: a. The POCs, dated 11/3/24 to 1/1/24 and 1/2/24 to 2/15/24, included physician orders for skilled nursing and home health aide services. b. The home health aide care plans, dated 11/3/24 and 1/3/24, directed the home health aide to complete a shower every visit and may complete a sponge bath per nurse direction. c. Home Health Aide visit note, dated 12/18/24, failed to include documentation the aide performed the task of shower, and failed to document why the task was not performed. The document also failed to include direction given for the sponge bath by the nurse. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training. According to the agency policy, Home Health Aide Plan of Care, dated 4/2018, The home health aide plan of care will be individualized to the specific patient and will include the type of services/procedures to be provided, such as hands on personal care, and Specific procedure to be performed, including amount, frequency, and duration. Interview 11/5/24, at 3:05 PM with Staff Q, Clinical Supervisor, reported if the aide is unable to complete an assigned task, the aide performing the visit will contact the case manager. 1.Patient #11 had a start of care date of 5/21/24 and received services out of the Carroll office. Clinical record review revealed: a. The Plan of Care (POC), dated 5/21/24 to 7/19/24, included direction to the aide to perform a shower every visit. b. Home Health Aide visit notes, dated 5/21/24 and 5/28/24, completed by Staff R, Home Health Aide, failed to include documentation the aide performed the task of shower, and failed to document why the task was not performed. The home health aide failed to provide services that are ordered by the physician, included in the plan of care, permitted under state law, and consistent with home health aide training.”

“Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This Element is not met as evidenced by: Based on observations, clinical record reviews, agency policy review and staff interview, the agency failed to ensure the patient’s clinical record included accurate and specific documentation of interventions and maintained pertinent current information in the patient record for 4 of 8 sampled patients (Patients #3, #4, #5 and #10) with wounds. Failure to ensure the patient’s clinical record included pertinent current and accurate documentation of interventions placed agency patients at risk for not receiving the correct interventions and for other disciplines providing services to have unclear or inaccurate information regarding the patient’s condition. Findings include: 4. Patient# 3 had a start of care date of 8/2/24 and received services out of the Coon Rapids office. Clinical record review revealed: a. The Plan of Care, dated 8/2/24 to 9/30/24, included physician order for skilled nurse to instruct on disease management for hepatic encephalopathy and diabetic management. b. Skilled nurse visit note, dated 9/16/24, included documentation of open wounds assessed to both lower extremities along with areas of dried serosanguineous drainage, right lower extremity has a few scattered fluid filled areas assessed, areas of drainage cleansed from the skin with warm soap and water, pat dried. c. Interim physician order, dated 9/16/24, included skilled nurse to perform skin care to bilateral lower extremities 1-2 times per week as follows: cleanse areas with wound cleanser and gauze, pat dry, cover open areas, weeping sites with a foam bordered dressing until resolved. d. The Plan of Care, dated 10/1/24 to 11/29/24, included physician order for skilled nurse to perform skin care to bilateral lower extremities 1-2 times per week as follows: cleanse areas with wound cleanser and gauze, pat dry, cover open areas, weeping sites with a foam bordered dressing until resolved. e. Interim physician order, dated 10/7/24, included skilled nurse to apply Coflex TLC Zinc Lite (or similar) two-layer lite compression wraps (20-30 mmHg) to bilateral lower extremities, cover wraps to bilateral lower extremities with Nylon Stocking, wraps to be changed 1-2 times weekly. f. Skilled nurse visit note, dated 10/23/24, included documentation bilateral lower extremities much more red and irritated appearing today verses last week. Patient not compliant with amoxicillin for open wounds on legs, physician notified. Areas of diffuse impaired skin integrity assessed at this visit. Multiple areas of dried, serosanguinous scabbed areas assessed throughout lower extremity. Right posterior lower extremity deep red in color with open, pin-point wounds assessed. g. Skilled nurse visit note, dated 10/25/24, included documentation patient’s right lower extremity has multiple open wounds draining small to moderate amounts of serosanguinous drainage. Open wounds assessed throughout right shin and medial lower extremity, wound beds bright red in color. Left lower extremity has some red, open, draining wounds, less then right lower extremity. Left lower extremity has multiple scabbed wounds. The skilled nurse failed to measure open wounds per agency policy. The above findings were reviewed with the Administrator, General Manager, Clinical Manager, Clinical Supervisor and Quality Assurance Nurse 3. Patient #4 had a start of care date of 9/20/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The POC, dated 9/20/24 to 11/18/24, included physician orders for skilled nursing services 1-2 times weekly for assessment and management of patient with chronic venous stasis ulcers on both lower extremities. b. Skilled Nurse visit notes, dated 9/23/24, 9/30/24,10/8/24, 10/10/24,10/14/24,10/22/24, and 10/29/24, revealed the patient had multiple open ulcers on both lower extremities, included multiple photographs of open wounds, but failed to include measurements of the open areas. Skilled nurse failed to document wound measurements for the opened areas on both of the patients lower legs. 2. Patient #10 had a start of care date of 11/3/24 and received services out of the Elk Horn office. Clinical record review revealed the following: a. The POCs, dated 11/3/23 to 1/1/24 and 1/2/24 to 2/15/24, included physician orders for skilled nursing services 1-2 times weekly for assessment of patient with cellulitis of groin, cellulitis of abdominal wall localized adiposity, very low level of personal hygiene, other reduced mobility and pressure ulcer of unspecified part of back, stage 2. b. Skilled Nurse visit notes, dated 12/26/23, 1/2, 1/10, 1/17, 1/30/24 and 2/5/24, revealed the patient had a wound on the right mid flank, open stage 2 with a small amount serosanguineous drainage. The documents failed to include measurements of the open areas. Skilled nurse failed to document wound measurements for the opened areas on the patient’s According to the agency policy titled Wound Monitoring Guidelines, dated 4/11/24, all wounds or areas of impaired skin integrity will be assessed with each visit until healed unless care is planned otherwise. The nurse creates a wound on the wound worksheet for any of the following: any open wound, any scabbed or necrosis caused by trauma or surgery, any pressure ulcer and any surgical incision until attachment devices are out and there is no longer any inflammation. Wounds are to be measured (length by width by depth in centimeters) weekly. 1.Patient #5 had a start of care date of 9/27/24 and received services out of the Carroll office. Clinical record review revealed the following: a. The Plan of Care (POC), dated 9/27/24 to 11/25/24, included physician orders for skilled nursing services 1-2 times weekly for observation, assessment and education for wound management related to diabetic and vascular ulcers. b. Skilled Nurse visit notes, dated 10/1/24, 10/4/24, 10/11/24, 10/18/24, 10/22/24, 11/1/24 and 11/5/24 revealed pictures to the left distal lower leg and identified wound care was completed per orders on the POC. c. During a home visit observation on 11/5/24 at 1:00 PM with Staff K, Registered Nurse (RN), Staff K provided wound care and identified Patient #5 had newly opened areas to the left lower leg. During an interview at this same visit, Staff K stated we don’t measure diffused open areas as they change frequently. We take photographs but don’t measure each open area. Skilled nurse failed to document wound measurements for the existing and newly opened areas on the patient’s left distal lower leg.”