Iowa Home Care, L L C

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on clinical record review, agency policy review and home visit observation, the agency failed to ensure staff provided care in accordance with accepted infection control standards of practice observed during a home visit for 2 of 4 sampled patients (Patients #1 and #3) with home visits. Failure to follow accepted standards of practice for infection control may put the patient at risk of receiving unsafe care or care that allows the spread of infection. Findings include: 2. Patient #1 had a start of care date of 7/10/25. Clinical record review revealed: a. The POC, dated 7/5/26 to 9/2/26, identified the patient had a primary diagnosis of vascular dementia and included physician orders for skilled nursing services 3 times a week. b. During a home observation visit on 8/31/26 at 4:00 PM with Staff I, RN, the surveyor observed Staff I to check the patient’s vital signs using a stethoscope, thermometer, pulse oximeter and blood pressure cuff. The surveyor observed Staff I clean each piece of vital sign equipment after use and then placed the equipment directly on the patient’s end table without a barrier. The surveyor observed Staff I putting the equipment back in a zippered bag at the end of the visit without sanitizing the equipment. Staff I, RN failed to sanitize all contaminated items prior to returning them to the nursing bag. The above findings were reviewed with the Administrator, Corporate Clinical Lead, Chief of Organizational Performance and Quality Assurance and Performance Improvement Coordinator. According to agency policy, titled Infection Control – Hand Hygiene, dated 06/2026, hand hygiene must be performed: before and after touching patient’s intact skin, after removing gloves, before preparing medications, before and after performing a procedure. According to agency policy, titled Infection Control – Bag Technique, dated 06/2026, upon entering the patient’s home, place the bag in a clean place, perform hand hygiene, open bag and remove needed items from bag, place items on clean surface or on a barrier, close bag, provide patient care, clean/disinfect reusable items before returning them to the bag, perform hand hygiene and put reusable items back in bag. Perform hand hygiene after all cares, all documentation, just before leaving home. 1. Patient #3 had a start of care dated of 7/15/25. Clinical record review revealed Plan of Care, dated 7/10/26 to 9/7/26, included primary diagnosis of amyotrophic lateral sclerosis (ALS) and physician orders for skilled nursing services. The surveyor accompanied Staff F, Licensed Practical Nurse (LPN), to a home visit on 9/1/26 at 8:00 AM Staff F failed to complete hand hygiene at start of visit prior to putting gloves put on. After pouring Jevity into feeding bag, Staff F removed gloves and failed to complete hand hygiene. Staff F went out to kitchen to obtain water and pour liquid medication into a med cup, carried both items to bedside and placed on a small table, put on gloves, without completing hand hygiene. Staff F, LPN, administered medication per G-tube and hooked up G-tube feeding, removed gloves and failed to complete hand hygiene. LPN left home without completing hand hygiene after all cares. LPN failed to complete hand hygiene per agency policy and accepted standards of practice.”

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on agency staff interview, clinical record review, personnel file review and agency policy review, the agency failed to ensure 1 of 1 sampled home health aides (Staff Q) had documented evidence of competency in the performance of tracheostomy care, which exceeded the level of basic home health aide skills, in the presence of a registered nurse prior to being assigned to perform the task independently for 1 of 1 sampled patients (Patient #8) requiring tracheostomy care. The agency provided home health aide services to 320 patients at the time of the survey and employed 83 home health aides. Failure to ensure home health aides have a competent ability to perform all skills above and beyond basic home health skills increased the risk for patients to receive inadequate or inappropriate care. Findings include: The Medicare Conditions of Participation require home health agencies to determine competence of home health aides in those skills which exceed the general basic home health aide skills areas prior to assigning the home health aide to a patient who would require the task be performed. According to the agency policy titled Home Health Aide Care Plan, dated 6/2026, the patient’s Registered Nurse (RN) Case Manager or other appropriate skilled professional will develop the written home health aide plan of care, consistent with the comprehensive plan of care and physician orders. Patient #8 had a start of care date of 12/19/25. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to provide tracheostomy care-may need to assist patient with cleaning secretions/sputum from outside of tracheostomy using a cotton swab, gauze or tissue, wiping down the metal parts on the patient’s neck. Do not remove. b. Review of the clinical record showed Staff Q, Home Health Aide, provided aide services independently for Patient #8. c. Staff Q, Home Health Aide, had a hire date of 11/18/24. Staff Q’s personnel file lacked any documentation verifying that an RN had observed and evaluated the home health aide to confirm competence in performing tracheostomy cares. During an interview on 9/2/26 at 10:42 AM, Staff D, Chief of Organizational Performance reviewed Staff Q’s personnel file and confirmed the file contained no documentation or evidence of training and competency evaluation regarding tracheostomy cares. The agency failed to ensure home health aides successfully completed a competency evaluation in assigned extra skills prior to performing the extra skills. The above findings were reviewed with the Administrator, Corporate Clinical Lead, Chief of Organizational Performance and Quality Assurance and Performance Improvement Coordinator.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (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 4 of 5 sampled patients with wounds (Patient #4, #5, #6 and #9). Failure to follow agency policies and procedures when providing patient care may result in inadequate and unsafe patient care practices. Findings include: 4. Patient #4 had a start of care date of 5/15/26. Clinical record review revealed: a. Plan of Care, dated 5/15/26 to 7/13/26 and 7/14/26 to 9/11/26, included primary diagnosis of pressure ulcer of right buttock, stage 3 and physician orders for skilled nurse and home health aide services. b. Resumption of care comprehensive assessment, dated 7/22/26, completed by Staff L, RN, included documentation wound care already performed today and dressing intact, will coordinate with patient’s caregiver and assess wound next week. c. Skilled nurse visit note, dated 7/23/26, completed by Staff B, Clinical Manager, included documentation blood sample collected but lacked documentation of wound assessment or measurements. The RN failed to complete wound measurements for the week of 7/19/26 through 7/25/26. Findings reviewed with the Administrator, Corporate Clinical Lead, Chief of Organizational Performance and QAPI Coordinator. 2. Patient #6 had a start of care date of 8/6/26. Clinical record review revealed: a. The POC, dated 8/6/26 to 10/4/26, identified the patient had a primary diagnosis of congestive heart failure. The POC included physician orders for skilled nursing to observe and assess wound and include wound measurements. b. The skilled nurse visit note dated 8/18/26, completed by Staff F, Licensed Practical Nurse (LPN), identified no wound noted today, skin chafing noted to buttocks but failed to include any measurements of the chafing. c. The skilled nurse visit note, dated 8/21/26, completed by Staff R, RN, identified the wound was assessed and is improving but failed to include any wound measurements. The skilled nurses failed to measure the patient’s wound as directed by the plan of care. 3. Patient #9 had a start of care date of 8/12/25 and a discharge date of 1/5/26. Clinical record review revealed: a. The POC, dated 10/6/25 to 12/4/25, identified the patient had a primary diagnosis of pressure ulcer of left heal, stage 3. The POC included physician orders for skilled nursing to observe and assess wound and include wound measurements. b. The skilled nurse comprehensive assessment at recertification, dated 12/1/25, completed by Staff S, RN, identified the wound assessed, wound care provided as ordered but failed to include any wound measurements. The skilled nurses failed to document a complete wound assessment, including wound measurements, at the time of the comprehensive assessment. According to agency policy titled Skin and Wound Care - Assessment: Wound, dated June 2026, wounds and patient change therefore wounds need to be re-assessed regularly and treated according to the changing needs of the patient and the wound. In home care, a professional reassessment of most wounds is usually indicated at least once a week or at a frequency that is medically necessary. Reassessment and document of the wound should include wound measurement, wound bed description and clinical evaluation of the wound progress. During an interview on 9/1/26 at 2:35 PM, the Clinical Manager reported that wounds should be measured weekly and include length, width and depth in centimeters. 1. Patient #5 had a start of care date of 7/21/26. Clinical record review revealed: a. The plan of care (POC), dated 7/21/26 to 9/18/26, included a primary diagnosis of juvenile osteochondrosis of tibia tubercle, bilateral and physician orders for weekly skilled nursing services. b. The skilled nurse visit note, dated 7/31/26, completed by Staff O, Registered Nurse (RN), included documentation that the patient had wounds. The assessment lacked documentation of wound measurements per agency policy. c. The skilled nurse visit note, dated 8/28/26, completed by Staff P, RN, included documentation that the dressing was changed to the right shin wound. The assessment lacked documentation of wound measurements per agency policy. The nurse failed to document wound measurements, including length, width and depth, weekly per agency policy.”

“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 a home observation visits, patient interview, clinical record review, staff interview and agency policy review, the agency failed to ensure accurate completion of all components comprising the plan of care (POC), including all medication and supplies and equipment used by the patient for 3 of 10 sampled patients (Patients #1, #2 and #6). Failure to maintain complete and accurate POCs with current orders placed the patient at risk to not receive services, supplies, and/or medication according to assessed needs and physician orders. Findings include: 2. Patient #1 had a start of care date of 7/10/25. Clinical record review revealed: a. The POC, dated 7/5/26 to 9/2/26, identified the patient had a primary diagnosis of vascular dementia and included orders for skilled nursing services to provide home medication management which includes verification that physician ordered medications are being taken as ordered with each home visit. b. During a home observation visit on 8/31/26 at 4:00 PM with Staff I, RN, the surveyor observed the following medication discrepancies while the RN set up the patient’s medication in a medication planner: 1) The agency medication list, printed 8/31/26, identified the patient takes magnesium 400 milligrams (mg) (as magnesium oxide) tablets with instructions to take 1 tablet at bedtime. The bottle in the home was labeled magnesium glycinate (supplement) with 240 mg of magnesium per 2 capsules and the RN placed 2 capsules in each bedtime slot. The bottle had 10 capsules out of 120 capsules left. 2) The agency medication list identified the patient takes Myrbetriq (for overactive bladder) 50 mg extended release tablets with instructions to take 1 tablet in the morning. The bottle in the home was labeled 25 mg with instructions to take 1 tablet in the morning. The bottle was last filled on 6/7/26. The agency nurse failed to ensure physician ordered medications were being taken as ordered with each home visit. 3. Patient #6 had a start of care date of 8/6/26. Clinical record review revealed: a. The POC, dated 8/6/26 to 10/4/26, identified the patient had a primary diagnosis of congestive heart failure. The POC included the following medical equipment and supplies used by the patient: gait belt, grab bars, hospital bed, incontinent supplies, medication planner, reacher, shower chair, urinal, walker and wheelchair. b. The occupational therapist visit note from start of care, dated 8/11/26, completed by Staff T, Occupational Therapist, identified the patient also uses a commode, toilet riser and toilet safety frame. The agency failed to include all medical equipment and supplies on the patient’s POC, including commode, toilet riser and toilet safety frame. The above findings were reviewed with the Administrator, Corporate Clinical Lead, Chief of Organizational Performance and Quality Assurance and Performance Improvement Coordinator. According to the agency policy titled Care Planning Process, dated June 2026, the patient specific clinical plan of care includes medications including dose/frequency/purpose. The POC will be revised as frequently as deemed necessary by the clinician based on the ongoing assessments of the patient. Clinicians will inform the patient’s physician (or other authorized licensed independent practitioner) of any changes that suggest a need to alter the plan of care. Changes must be written, dated and signed by the professional making the changes. 1. Patient #2 had a start of care date of 6/13/25. Clinical record review revealed the following: a. The POC, dated 8/7/26 to 10/5/26, identified that the patient had a primary diagnosis of Type 2 diabetes mellitus with hyperglycemia and included physician orders for cyanocobalamin 2,500 micrograms (mcg) 1 tablet once per day. The POC identified the patient as receiving weekly skilled nursing visits. b. During a home observation visit on 8/31/26 at 2:00 PM with Staff E, Registered Nurse (RN), medication reconciliation revealed that the bottle of cyanocobalamin in the home was labeled with a strength of 5,000 mcg. c. During an interview on 8/31/26 at 2:00 PM, Staff E reported that sometimes patients provide over the counter medication at a different strength than what is prescribed. d. During an interview on 8/31/26 at 2:00 PM, the patient reported taking cyanocobalamin 5,000 mcg since before starting with the home health agency. The agency failed to ensure the patient’s POC accurately reflected the patient’s current medications.”

“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 clinical record review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 1 of 3 sampled patients with Physical Therapy interim orders. (Patient #10). Failure to update the Plan of Care increased the potential for inaccurate provision of care. Findings include: According to agency policy, titled Care Planning Process, dated 06/2026, identified the patient-specific clinical plan of care includes all patient care orders including verbal orders. Patient #10 had a start of care date of 6/18/26 and a discharge date of 8/12/26. Clinical record review revealed: a. Plan of Care, dated 6/18/26 to 8/16/26, included primary diagnosis of post-cholecystectomy syndrome (digestion problems continue after gallbladder removed) and physician orders for skilled nursing services 2 times a week for 14 days and physical therapy services to evaluate. b. Physical therapy evaluation, dated 6/23/26, completed by Staff U, Physical Therapist (PT), included documentation therapy would continue 1 time a week for 1 week and 2 times a week for 7 weeks. c. Updated plan of care, dated 8/11/26, failed to include physician orders for physical therapy services identified on 6/23/26. During an interview on 9/2/26 at 8:55 AM, Staff M, QAPI (Quality Assurance and Performance Improvement) Coordinator, reported she reviewed the clinical record and confirmed the PT orders were not flowing to the updated plan of care as required. The clinical record lacked an updated plan of care that included all interim physician orders per regulations. The above findings were reviewed with the Administrator, Corporate Clinical Lead, Chief of Organizational Performance and Quality Assurance and Performance Improvement 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, agency 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 (POC) and/or as directed by the skilled professional assigning the home health aide to the patient for 3 of 7 sampled patients receiving home health aide services (Patients #4, #5 and #9). The agency reported 320 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: 3. Patient #4 had a start of care date of 5/15/26. Clinical record review revealed: a. Plan of Care, dated 7/14/26 to 9/11/26, included primary diagnosis of pressure ulcer of right buttock, stage 3 and physician orders for skilled nurse and home health aide services. b. Aide care plan, dated 7/13/26, included the following tasks: i. bathing – offer shower first, partial second, identify type of bath in comment box; ii. shave legs – every Thursday; iii. empty down (foley catheter) bag each visit and document output; and iv. passive range of motion to bilateral upper and bilateral lower extremities M-W-F (Monday, Wednesday and Friday). c. Aide visit notes, dated 8/16/26, Sunday, and 8/31/26, Monday, completed by Staff J, Home Health Aide (HHA), included documentation a bed bath was given instead of shower or partial bath. d. Aide visit note, dated 8/17/26, Monday, completed by Staff J, HHA, included documentation empty down bag was performed but no amount of output was documented, and range of motion was not performed as not Tuesday or Thursday. e. Aide visit note, dated 8/25/26, Tuesday, completed by Staff K, HHA, included documentation bed bath was given instead of shower or partial bath, empty down bag was performed but no amount of output was documented, and range of motion was performed. f. Aide visit note, dated 8/26/26, Wednesday, completed by Staff J, HHA, included documentation a bed bath was given instead of shower or partial bath, empty down bag was performed but no amount of output was documented, and range of motion was not performed as not the day. g. Aide visit note, dated 8/27/26, Thursday, completed by Staff K, HHA, included documentation a bed bath was given instead of shower or partial bath, empty down bag was performed but no amount of output was documented, and range of motion was performed. h. Aide visit note, dated 9/1/26, Tuesday, completed by Staff K, HHA, included documentation the bathing task was completed but failed to identify which bath was provided, empty down bag was performed but no amount of output was documented, and range of motion was performed. The aides failed to complete tasks as assigned on the aide care plan. Findings reviewed with the Administrator, Corporate Clinical Lead, Chief of Organizational Performance and QAPI Coordinator. 2. Patient #9 had a start of care date of 8/12/25. Clinical record review revealed: a. The POC, dated 10/6/25 to 12/4/25, identified the patient had a primary diagnosis of pressure ulcer of left heal, stage 3 and included orders for skilled nursing and home health aide services. b. The aide care plan included a task for bathing hierarchy instruction to offer a shower first, partial second and identify type of bath in comment box every visit. c. The aide visit notes, dated 11/12/25, 11/19/25, 11/21/25 and 11/28/25, completed by Staff G, Home Health Aide, identified a bed bath completed. The home health aide failed to provide services only as directed by the RN on the home health aide care plan. According to agency policy titled Home Health Aide Care Plan, dated June 2026, when there is a deviation or refusal of care assigned to the home health aide by the patient and/or patient’s family, the home health aide will notify the RN Case Manager for appropriate care planning and follow-up. This notification would be documented in the patient’s clinical record. During an interview on 9/1/26 at 2:35 PM, the Clinical Manager reported that home health aides are not to complete an unassigned task without specific direction from a Registered Nurse (RN). 1. Patient #5 had a start of care date of 7/21/26. Clinical record review revealed the following: a. The POC, dated 7/21/26 to 9/18/26, included that the patient had a primary diagnosis of juvenile osteochondrosis of tibia tubercle, bilateral and physician orders for skilled nurse and home health aide services. b. The aide care plan, dated 7/21/26, identified the following home health aide tasks: bed bath, assist client with undressing/dressing, apply lotion to torso/extremities, oral care, shampoo hair, assist client with wiping/cleansing/drying perineal area, check skin and urinary pad. c. The home health aide visit note, dated 7/30/26, completed by Staff N, Home Health Aide, included documentation that prescription lotion was applied to the patient’s torso and extremities. The agency failed to ensure the home health aide performed aide care as directed by the RN on the aide care plan.”

“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 clinical record review, 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 1 of 1 sampled patients with physician orders for international normalized ratio (INR). 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: According to the agency policy titled Clinical/Service Data Collection, dated 6/2026, entries in the clinical record will be made on the day care/service is provided to the patient. The clinical note will include what care/service was provided, treatment and/or procedure performed, patient response to treatment, the date the service was provided, the signature of the clinician and his/her credentials. Patient #1 had a start of care date of 7/10/25. Clinical record review revealed: a. The POC, dated 7/5/26 to 9/2/26, identified the patient had a primary diagnosis of vascular dementia and included physician orders for skilled nurse to obtain International Normalized Ratio (INR) via patient’s home machine weekly, typically Friday (unless ordered otherwise) and coordinate with the patient’s primary care physician for dosing of anti-coagulant medication. b. The skilled nurse visit notes, dated 8/14/26 and 8/21/26, completed by Staff I, Registered Nurse (RN), failed to include documentation an INR was obtained. During an interview on 9/2/26 at 12:20 PM, Staff C, Corporate Clinical Lead, identified Staff I did obtain the INR on 8/14/26 and 8/21/26 as evidenced by the patient’s primary physician’s notes but failed to document the information in the patient’s home health electronic medical record. The agency failed to ensure the patient’s clinical record included all current and accurate documentation of interventions, including documentation of obtaining weekly INRs. The above findings were reviewed with the Administrator, Corporate Clinical Lead, Chief of Organizational Performance and Quality Assurance and Performance Improvement Coordinator.”

“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 policy review, clinical record review and agency staff interview, the agency failed to provide medications, treatments or services only as ordered by the physician for 1 of 1 sampled patients with orders for wound assessments (Patient #3). Failure to ensure staff obtain physician orders for administration of medications, treatments or services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. Findings include: According to agency policy, titled Care Planning Proscess, dated November 2024, the patient-specific clinical plan of care (POC) includes: all patient care orders including verbal orders. According to the undated agency policy, titled Skin and Wound Care-Assessment: Wound, wounds and patients change therefore wounds need to be re-assessed regularly and treated according to the changing needs of the patient and the wound. In home care, a professional reassessment of most wounds is usually indicated at least once a week. Basic wound assessment for all wounds, dimensions: length, width, and depth, presence of tunneling or undermining, shape, wound bed tissue, wound edges, surrounding skin, drainage and pain. During an interview on 2/5/26 at 9:10 AM, Staff C, Corporate Clinical stated the agency did not have documentation of wound assessment on 1/22/26. Patient #4 had a start of care date of 9/4/25. Review of the clinical record revealed the following: a. The POC, dated 1/2/26 to 3/2/26, identified the patient had diagnosis that included Amyotrophic lateral sclerosis (ALS) and included orders for skilled nursing services 1 time a week to observe and assess wuonds. Assessment to include wound location, wound measurements (width/length/depth). Change dressing to pressure ulcer on right buttock: remove old dressing, cleanse with soap and water, apply thin layer of triple antibiotic ointment and bandaid, change 2 to 3 times a week and when soiled. b. The skilled nurse visit note, dated 1/22/26, Staff H, Licensed practical nurse (LPN), documented the dressing changed to the right buttock per orders. The note lacked documentation of an assessment of the patients wound, or assessment of wound measurements. c. The wound assessment form, dated 11/6/25 through 1/30/26, identified the patient had a stage 2 pressure area to the right buttock. The assessment form lacked documentation of a wound assessment or assessment of the wound measurements on 1/22/26. The clinical record lacked completion of the physician orders per the patient’s POC. The above findings were reviewed with the agency Administrator, Chief of Organizational Performance, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead, RN.”

“Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA’s policies and procedures. This Standard is not met as evidenced by: Based on patient interview, agency staff interview, clinical record reviews and agency policy review, the agency failed to ensure clinicians followed agency policies and procedures when inserting an indwelling catheter for 1 of 5 sampled patients (Patient #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 the agency policy titled Genitourinary System-Indwelling Catheter Insertion for Female, in pertinent part, adhere to standard precautions and explain procedure to patient. To perform catheterization, lubricate the catheter with water soluble lubricant to minimize urethra trauma. During an interview on 9/30/25 at 10:14 AM, Staff B, Clinical Manager reported skilled nurses are expected to follow the agency catheterization policy and to notify the physician immediately regarding any deviation to the policy. Patient #4 had a start of care date of 7/9/21. Clinical record review revealed the following: a. The Plan of Care (POC), dated 8/17/25 to 10/25/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included orders for skilled nursing services. b. The skilled nurse visit note, dated 9/1/25, completed by Staff C, Registered Nurse (RN), identified catheter changed and patient tolerated well. c. An incident report, dated 9/5/25, completed by Staff C, RN, detailed the catheterization stating at one point the catheter tip became dry and the tip of the catheter kept sliding toward the opening of the vagina. Skilled nurse took another sterile, clean catch catheter, got olive oil from the kitchen, put it in a clean cup from the dishwasher, used the clean catch catheter tip to point to the opening of the vagina for mapping purposes, lubricated the tip of the other catheter for insertion with olive oil and inserted the catheter. Skilled nurse noted clear, yellow urine in bag and no bleeding. d. During an interview on 9/30/25 at 1:30 PM, Staff C, RN confirmed the above information from the incident report. e. During an interview on 9/30/25 at 8:59 AM, Patient #4 identified a nurse came to her home on 9/1/25 to change her catheter and struggled with insertion. The nurse used all of the lubricant on one catheter and then brought in another catheter. Patient reported instead of the nurse taking out the catheter she couldn’t get in, she left it in while putting a second catheter in. The nurse needed more lubricant and patient told her she didn’t have any in the home so she used cooking oil from the kitchen. After the nurse got the second catheter in, she took the first one out. Patient reported feeling sore and had blood clots in the catheter tubing. The skilled nurse failed to follow agency procedure for insertion of an indwelling catheter. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on staff interview, clinical record review and agency policy review, the agency failed to promptly notify the physician of changes in the patient condition or needs that suggest an alteration to the plan of care for 1 of 5 sampled patients receiving catheter cares (Patient #4). Failure to report changes in patient condition or identified needs placed agency patients at risk for inadequate or inappropriate care. Findings include: According to the agency policy, titled Incident Reporting, dated October 2024, an incident is an unusual event involving organizational personnel, a patient, and family/caregiver. An incident is any happening that is not consistent with the routine operation of the organization or the routine care of a patient. When an incident occurs, an incident report form should be completed within 24 hours of the knowledge of the incident, supervisor should be notified immediately, preferably within 24 hours, and there should be follow up with the patient and family/caregiver, and/or patient’s physician. During an interview on 9/30/25, Staff B, Clinical Manager, stated incidents should be documented within 24 hours of the occurrence and the physician should be notified. Patient #4 had a start of care date of 7/9/21. Clinical record review revealed: a. The Plan of Care, dated 8/17/25 to 10/15/25, identified the patient had a diagnosis of chronic obstructive pulmonary disease and included physician orders for skilled nursing services 1 time a week. b. The skilled nurse visit note, dated 9/1/25, completed by Staff C, Registered Nurse (RN), identified Staff C changed Patient #4’s catheter and the patient tolerated well. c. An incident report form, dated 9/5/25 (3 days late according to agency policy), completed by Staff C, RN, detailed an incident that occurred on 9/1/25 during Patient #4’s catheter change. d. During an interview on 9/30/25, a Patient Care Technician from Patient #4’s physician’s office, denied seeing any information in Patient’s #4’s clinical record identifying the home care agency notified the physician of the incident that occurred during Patient #4’s catheter change on 9/1/25. The Patient Care Tech identified the physician was made aware of the issue when the patient presented to the clinic on 9/4/25 to have catheter checked and to make sure there was no infection due to incident on 9/1/25. The home health agency failed to promptly notify the physician when Patient’s #4’s catheter change didn’t follow routine procedure. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.”

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on agency staff interview, patient and family interview, agency policy review and clinical record review, the agency clinician’s failed to communicate with other staff, the patient and the caregiver regarding missing scheduled visits as identified by agency policy for 1 of 6 sampled patients. Failure to communicate with other staff, patient and caregiver placed the patient in a position to not receive needed cares and interventions as ordered in the plan of care. Findings include: According to agency policy, titled Care/Service Coordination, dated 11/24, identified it is the responsibility of the Registered Nurse Case Manager to facilitate communication about changes in the patient status among assigned personnel. Timely and ongoing communication is the responsibility of each team member of the interdisciplinary group and will be appropriate to the needs and abilities of the patient, and relevant to the care/service provided. According to agency policy, titled Care Planning Process, dated 11/24, identified changes in the plan of care will be noted with the following documentation: assessment, plan of care with clinical outcome goals, care plan with specific services/actions to be taken, clinical notes and verbal orders. During an interview on 9/30/25 at 2:30 PM, Staff A, Agency President, reported agency expectation is for staff to call into the office 2-4 hours in advance of missing work. Staff are to talk with scheduler, scheduler should ask nurses what visits can be moved and what visits need covered for the day. Care coordination department is responsible for notifying patients of schedule change. Some nurses prefer to call patients themselves as well as following above process. Patient #1 had a start of care date of 7/15/25. Clinical record review revealed the following: 1. Plans of Care, dated 7/15/25 to 9/12/25 and 9/13/25 to 11/11/25, included diagnosis of Amyotrophic Lateral Sclerosis (ALS) and orders for skilled nursing services 5 visits per week. 2. Care coordination note, dated 8/14/25, identified coordination meeting with home care staff, private nursing staff and family. 3. Missed visit notes, dated 8/18/25 and 8/19/25, identified nurse unable to go at requested time for visit so family/patient declined need for skilled nurse visit today. 4. Care coordination note, dated 8/19/25 at 9:06 AM, identified RN clinical manager left message for patient after RN case manager started receiving text messages from patient and caregiver wondering where nurse was at, as nurse was scheduled to arrive at 8:00 AM. Nurse scheduled was out ill and supervisor had covered visit later in the day, unaware that visit needed to be from 8:00 AM to 8:30 AM due to private care staff in the home at other time later in the day. 5. Care coordination note, dated 8/20/25, identified summary of new patient cares, reasons for home care, outcome of meeting on 8/14/25 was for home care to provide skilled nurse services 5 days per week, Monday through Friday from 8:00 AM to 8:30 AM. 6. Missed visit note, dated 9/10/25, identified nurse out ill today and patient/caregiver declined need for skilled nurse visit today. 7. Missed visit note, dated 9/22/25, identified regular nurse unavailable at regularly scheduled visit time, cares will resume on 9/23/25. 8. Missed visit note, dated 9/29/25, identified no service needed for today. During an interview on 9/29/25 at 1:50 PM, Staff A, Agency President, reported Patient #1 has another payor source in the home. Patient/family came to home health agency asking to provide skilled nursing for patient 5 days per week from 8:00 AM to approximately 9:00 AM, this would allow patient to continue to receive other payor source services due to a recent changes and patient’s need to utilize a home care service to the full extent before other payor source would cover the services. During an interview on 9/29/25 at 2:05 PM, Staff A, Agency President, reported the scheduled nurse for 9/29/25 was not aware the visit needed to be made at 8:00 AM, nurse had not made visit and had not contacted patient or family at time of interview. Office staff contacted family and 9/29/25’s visit was declined. During a home observation visit on 9/30/25 at 7:55 AM, Patient #1 reported problem is the agency staff don’t show up. Patient #1 has his/her mom or other people as back up when agency staff don’t show up as scheduled. During an interview on 9/30/25 at 10:01 AM, Patient #1’s mother reported problems with home health staff not showing up, staff don’t call or cancel visit. When no one shows up, mother calls office but no one is in the office until 8:00 AM. Mother working with agency staff to figure this out. Skilled nurses and agency staff failed to notify patient and family timely of not making visits at requested scheduled timeframe as agreed upon. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on agency staff interview, agency job description review and clinical record review, the agency failed to ensure a registered nurse (RN) completed licensed practical nurse (LPN) supervision for 1 of 3 sampled patients with LPN services. (Patient #1) Failure to supervise licensed practical nurse services, increased the risk that patients received unsatisfactory or inappropriate care from licensed practical nurses. Findings include: According to agency job description, titled Registered Nurse Case Manager, dated 5/18, Registered Nurse Case Manager directs, supervises and educates LPNs, personal care and support service staff, patients/consumers and family members. During an interview on 9/30/25 at 2:30 PM with Staff A, Agency President, reported LPN supervision is completed at a minimum at the time of recertification. Patient #1 had a start of care date of 7/15/25. Clinical record review revealed the following: 1. Plans of Care, dated 7/15/25 to 9/12/25 and 9/13/25 to 11/11/25, included diagnosis of Amyotrophic Lateral Sclerosis (ALS) and orders for skilled nursing services 5 visits per week. 2. Skilled nurse visit notes, dated 8/26/25, 8/28/25, 9/2/25 and 9/4/25, completed by LPNs, identified services were provided. 3. Recertification comprehensive assessment, dated 9/8/25, identified supervision was not applicable. During an interview on 9/30/25 at 2:40 PM, Staff A, Agency President, confirmed no LPN supervision had been completed at recertification time point for Patient #1. The above findings were reviewed with the Agency President, Corporate Clinical Lead, QAPI Coordinator, Clinical Manager and Chief of Organizational Performance.”

“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, the agency failed to ensure home health aides provided care to agency patients as ordered by the physician, permitted under state law and/or as directed by the skilled professional assigning the home health aide to the patient for 1 of 6 sampled patients (Patient #5). Failure to ensure 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 increased the risk that patient’s personal care needs were not safely and/or adequately met. Findings include: Patient #5 had a start of care date of 3/23/23. Clinical record review revealed the following: a. The Plan of Care (POC), dated 1/17/24 to 3/16/24, included physician orders for home health aide services to assist with personal cares and transfers using Hoyer lift. b. On 3/8/24, Staff G, Home Care Aide, reported an incident where she was transferring Patient #5 in the Hoyer lift. Documentation revealed Staff G closed the legs of the Hoyer lift to get under Patient #5’s bed better and the Hoyer lift tilted, causing Patient #5 to fall to the floor. The home health aide failed to utilize the Hoyer lift per agency guidelines and training.”