Pella Regional Home Health Agency

“Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner’s issuing orders for the HHA plan of care. This Element is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to report changes in patient needs to the physician for 1 of 1 sampled patients with home visit medication set up (Patient #3). Failure to communicate the patient’s status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Assessment Policy, last revised 9/2021, the skilled nurse determines reassessment need: depending on plan of treatment. Frequency of visits is determined by Registered Nurse after initial visit is made and in cooperation under direction of certifying provider. Reassessments may be triggered by such things as : condition, progress towards goals, significant changes in condition, diagnosis changes, care, environment or support system change. Patient #3 had a start of care date of 12/9/25. Clinical record review revealed the following: a. The Plan of Care, dated 12/9/25 to 2/6/26, included the diagnosis of Bipolar disorder. The POC included physician orders for skilled nurse visits 1 time a week for medication set up and medication orders. The POC included the patient goal the patient will demonstrate effective medication management by taking medications as set up in weekly pill planner 90% of the time. b. The skilled nurse visit note, dated 1/6/26, Staff B, Registered Nurse (RN), documented the patient missed the PM doses 2 times. The clinical record lacked physician notification of missed medications. c. The skilled nurse visit note, dated 1/13/26, Staff B, RN, documented the patient missed multiple doses the past week. The clinical record lacked physician notification of missed medications. d. The skilled nurse visit note, dated 1/20/26, Staff B, RN, documented the patient missed 1 PM dose. The clinical record lacked physician notification of missed medications. e. During an observation home visit on 1/27/26 at 2:45 PM with Staff B, RN, the surveyor observed the mediset missed 3 evening doses that included 5 pills and one morning dose that included 5 pills. The agency failed to provide timely notification to the physician of missed prescribed doses of medications. The above findings reviewed with the Administrator/Clinical Manager.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to provide medication set up as ordered by a physician for 1 of 1 sampled patients with home visits for medication set up (Patient #3). Failure to ensure staff obtain physician orders for administration of services provided by agency staff, including medication set up, placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled as a clients condition and needs change, warranting a change in services, frequency of visits, treatments, etc,, the plan of care will be adjusted accourdingly under the direction of the ordering provider and the home health plan of care will be revised within the electronic medical record. Any deviation from the ordered plan of care requires a verbal or phone order to change the treatment. Patient #3 had a start of care date of 12/9/25. Clinical record review revealed: a. The Plan of Care (POC), dated 12/9/25 to 2/6/26, included a primary diagnosis of Bipolar disorder and orders for skilled nursing services and orders for medication set up and multiple medication orders.. b. An observational skilled nurse visit on 1/28/26 at 2:45 PM with Staff B, Registered Nurse (RN), the surveyor observed Staff B set up the following medications in the mediset: 1) Quetiapine 25 milligrams (mg), 1/2 tablet every moning, (the POC included 2 times a day as needed). 2) Prazosin 2 mg, 1 capsule every evening (the POC ordered administration at bedtime). 3: Atorvastatin 40 mg 1 tablet every evening (the POC ordered administration at bedtime). 4. Eszopicline 3 mg 1 tablet every evening (the POC ordered administration at bedtime). c. During an interview on 1/27/26 during the same home visit, the patient stated he/she had taken all the medications in the morning and evening at 5:00 PM for the past 6 months. The agency skilled nurse failed to set up the patient’s medications per the physicians order on the POC. The findings were reviewed with the Administrator/Clinical Manager.”

“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 to the physician and other health care professionals who would be providing care to the patient after discharge within 5 business days for 1 of 2 sampled patients transferred to another facility and 1 of 1 patients discharged from the agency and transferred to another facility. ( Patient #4, and #6) 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 Home Health Discharge/Transfer Criteria, last revised 9/2021, completion of a summary report for all transfers/discharges: Discharge sumary to be set within 5 business days (of the patient’s discharge) to the primary care practitioner or other health care professional who will be responsible for providing care to the patient after discharge from the agency. Transfer summary to be sent within 2 business days (for a planned transfer), if the patient’s care will be immediately continued in a health care facility; or Transfer suummary to be sent within 2 business days of becoming aware of an unplanned transfer, if the patinet is still receiving care in a health facility when the agency becomes aware of the transfer. During an interview on 1/28/26 at 9:10 AM the Administrator/Clinical Manager stated the nurse did not send a copy of the discharge summary to the receiving facility for Patient #4. 1.Patient #4 had a start of care date of 11/3/25. Clinical record review revealed the following: a. The Plans of Care (POC), dated 11/3/25 to 1/1/26 and 1/2/26 to 3/2/26, included orders for skilled nursing services and Physical Therapy services. b. The physical therapy note, dated 12/4/25 and signed by Staff E, Physical therapy assistant (PTA) on 12/8/25, documented staff E arrived at the patient’s home for acheduled appountment with no one at home. The agency scheduler reached out to the patient’s family and they reported the patient is going in for surgery in 30 minutes and they forgot to let the agency know. c. The comprehensive assessment at resumption of care, dated 12/10/25, documented the patient inpatient hospital with a discharge date of 12/9/25. d. The clinical record lacked documentation of a completed transfer summary. The agency failed to completed the transfer summary and send to the receiving facility within 2 business days of knowledge of the transfer to the hospital. 2. Patient #7 had a start of care date of 8/14/24 and discharge date of 12/24/24. Clinical record review revealed the following: a. The POC, dated 12/13/24 to 2/9/25, identified the patient had a diagnosis of cancer of the brain and included orders for skilled nursing services. b. The comprehensive assessment at discharge, dated 12/24/24, identified the patient requested services from a specific hospice. The nurse verified with the specific hospice via telephone call, the patient contact for services the same day. The physican contacted the home health agency and reported the specific hospice contacted him for services. c. The discharge summary, dated 12/31/25, included the patient discharged from the agency due to admission to hospice. The discharge summary sent to the physician. The documentation failed to include a copy of the discharge summary sent to the receiving hospice facility. The agency failed to send a copy of the discharge summary to the receiving hospice facility. The agency failed to completed 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.”