Iowa Home Care, L L C

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on agency staff interview and review of emergency preparedness training documentation, the agency failed to ensure training in emergency preparedness to all current staff annually. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. According to the agency’s policy titled Emergency During the review of the agency’s emergency preparedness plan, the training includes initial training in emergency preparedness policies and procedures and their assigned emergecny respone roles to all new and existing staff, individuals providing service under arragement, and volunteers if applicable. The training is provided at least every 2 years and demonstrates staff knowlege of emergency procedures. During an interview on 8/13/25 at 9:35 AM, the Administrator stated the contract agency failed to provide documentation training for Staff F, Physical Therapy Assistant (PTA) and Staff G, Occupational Therapist (OT) had been completed for the emergency preparedness plan. a. Staff F, PTA, had a hire date of 4/1/23. Review of the emergency prepardness documentation lacked training for the emergency preparedness plan. b. Staff G, OT, had a hire date of 8/8/24. Review of the emergency prepardness documentation lacked training for the emergency preparedness plan. The above findings were reviewed with the agency President, Administrator, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead RN.”

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review, staff interview and agency policy review, the agency failed to obtain the patient’s or the patient’s legal representative’s signature confirming he or she had received a copy of the notice of rights and responsibilities prior to the start of services for 1 of 7 sampled patients (Patient #7). Failure to obtain the patient’’s or the patient’s legal representative’s signature confirming they received a copy of the notice of the rights and responsibilities, placed the patient at risk to not have their rights protected and failed to promote the exercise of these rights. Findings include: According to the agency policy titled Patient Bill of Rights, dated November 2023, each patient will be an active, informed participant in his/her plan of care. To ensure this process, the patient will be empowered with certain rights and responsibilities as described. If a state court has not adjudged a patient to lack legal capacity to make health care decisions as defined by state law, the patient may designate someone to act as his/her representative to exercise the patient’s rights. This representative, on behalf of the patient, may exercise any of the rights provided by the policies and procedures established by the organization. The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights. The patient consumer service agreement will contain the acknowledgment of the patient’s receipt and review of the patient’s rights, responsibilities and privacy statement forms. The patient consumer service agreement will be signed by the patient or legal representative. During an interview on 8/12/25 at 4:10 PM Staff E, Corporate Clinical Lead, stated the agency had confusion with the assessment to start the contract with the pharmacy that provided the medication for the patient. She further stated the assessment drives the consent forms to start the services. The agency did the outcome and assessment information set (oasis) collection but had a hiccup with the consent forms. Patient #7 had a start of care date of 3/28/25 and was discharged from the agency on 5/22/25. Clinical record review revealed the following: a. The plan of care (POC), dated 3/28/25 to 5/22/25, identified the patient had the diagnosis of Alpha-1+antitrypsin deficiency. The POC included orders for skilled nurse services 1 time a week to provide intravenous (IV) access and Prolastin-C (alpha-proteinase inhibitor) IV medication administration. b. The skilled nurse visit at start of care, dated 3/28/25, included a hands on assessment and venipuncture for IV access in the right antecubital area with a 25 gauge needle. The medication Prolastin-C administered and the IV flushed with 10 ml normal saline. c. The electronic patient/consumer service agreement, dated 4/3/25, included Staff B, Clinical Manager and the patient’s signature the patient received a copy and explanation of their rights and responsibilities (6 days after the patient’s start of care). The agency failed to include evidence of the patient’s or the patient’s legal representative’s signature confirming they received a copy and explanation of their rights and responsibilities prior to the start of care. The above findings were reviewed with the agency President, Administrator, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead RN.”

“Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This Element is not met as evidenced by: Based on record review, staff interview and agency policy review, the agency failed to obtain the patient’s or the patient’s legal representative’s signature confirming he or she had consented to services with the knowlege of services provided and the charges the patient may have to pay before care is initiated for 1 of 7 sampled patients (Patient #7). Failure to obtain the patient’’s or the patient’s legal representative’s signature confirming they received a copy of the notice of the rights and responsibilities, placed the patient at risk to not have their rights protected and failed to promote the exercise of these rights. Findings include: According to the agency policy titled Informed Consent/Refusal of Treatment, dated October, 2024, upon admission and follow-up visits, the patient and family/caregiver will be given information (verbally and/or in writing) that describes: the services and/or disciplines anticipated to be involved in the care/service of the patient. During an interview on 8/12/25 at 4:10 PM Staff E, Corporate Clinical Lead, stated the agency had confusion with the assessment to start the contract with the pharmacy that provided the medication for the patient. She further stated the assessment drives the consent forms to start the services. The agency did the outcome and assessment information set (oasis) collection but had a hiccup with the consent forms. Patient #7 had a start of care date of 3/28/25 and was discharged from the agency on 5/22/25. Clinical record review revealed the following: a. The plan of care (POC), dated 3/28/25 to 5/22/25, identified the patient had the diagnosis of Alpha-1+antitrypsin deficiency. The POC included orders for skilled nurse services 1 time a week to provide intravenous (IV) access and Prolastin-C (alpha-proteinase inhibitor) IV medication administration. b. The skilled nurse visit at start of care, dated 3/28/25, included a hands on assessment and venipuncture for IV access in the right antecubital area with a 25 gauge needle. The medication Prolastin-C administered and the IV flushed with 10 ml normal saline. c. The electronic patient/consumer service agreement, dated 4/3/25, included Staff B, Clinical Manager and the patient’s signature, the patient received a copy and explanation of the services to be provided and liability for payment (6 days after the patient’s start of care). The agency failed to include evidence of the patient’s or the patient’s legal representative’s signature confirming they received a copy and explanation of the patient/consumer service agreement prior to the start of care. The above findings were reviewed with the agency President, Administrator, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead RN.”

“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 7 sampled patients (Patient #4). 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 Physician Provider Orders, dated October 2024, the individualized plan of care (POC) includes: all patient care orders including verbal orders and medications including dose/frequency/route/purpose. Patient #4 had a start of care date of 4/21/21. Review of the clinical record revealed the following: a. The POCs, dated 5/30/25 to 7/28/25 and 7/19/25 to 9/26/25, identified the patient had diagnosis that included myocardial infarction and included orders for medications with skilled nurse medication set up every other week, vital sign parameters for systolic blood pressure 80 to 160 and report abnormal values. The POC also included orders for the skilled nurse to assist the patient with change of glucometer devise and to observe and assess glucometer readings for patterns of hyper/hypo glycemia and report abnormal findings/concerns to physician. The POC also included order for an extra skilled nurse visit for recertification visits. b. The skilled nurse visit note, dated 6/11/25, Staff C, Licensed practical nurse (LPN) lacked documentation of the nurse assessed glucometer readings for patterns of hyper/hypo glycemia. c. The skilled nurse visit note, dated 7/8/25, Staff C, LPN, documented the visit and patient’s medication set up completed. The clinical record lacked documentation for an every other week visit scheduled for 7/22/25. d. The comprehensive assessment at recertification, dated 7/25/25, Staff Registered Nurse (RN) included documentation the dexcom (continuous glucose monitor) had not been in place since 7/22/25 and he/she ran out of medications on 7/22/25. The RN also documented the patient had taken his/her warfarin (blood thinner) and insulin. The comprehensive assessment lacked documentation of physician notification of missed medications and glucose monitoring. e. The skilled nurse visit note, dated 7/25/25, included documentation the patient’s systolic blood pressure reading at 162 (greater than ordered parameters of 160). The electronic clinical record lacked documentation of physician notification of the elevated blood pressure. The clinical record lacked completion of the physician orders per the patient’s POC. The above findings were reviewed with the agency President, Administrator, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead RN.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on home observation visit, clinical record review and agency policy review, the agency failed to obtain current medication orders for 1 of 3 sampled patients with a home observation visit (Patient #1). Failure to maintain complete and accurate Plans of Care with current orders placed the patient at risk to not receive services, medication and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Verification of Physician Orders, revised 10/2024, verbal orders will be spoke to, taken and documented only by professional, licensed home health personnel. All verbal orders received by home health professionals will be denoted with date/time of order receipt and will be documented in the patient’s clinical record. According to the agency policy titled Medication Profile, revised 10/2024, 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 new medication. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure the patient as well as other clinicians understand the medication regiment. Any conclusions and findings of patient medication use and monitoring should be communicated to the physician. Patient #1 had a start of care date of 4/10/23. Clinical record review revealed: a. The Plan of Care (POC), dated 7/28/25 to 9/25/25, identified the patient had a diagnosis of Chronic Obstructive Pulmonary Disease with exacerbation. The POC included orders for skilled nursing services and medications. b. During a home observation visit on 8/11/25 at 4:30 PM with Staff C, Licensed Practical Nurse (LPN), surveyor observed a bottle of oxycodone-acetaminophen 5 milligrams (mg)-325 mg with instructions to take 1 tablet by mouth every 6 hours as needed for pain. Bottle was last filled on 8/10/25. The agency medication profile identified oxycodone-acetaminophen 10mg-325mg oral tablets every 8 hours as needed for pain. During this same visit, patient reported he/she had taken the same dose of the medication for a long time; however, it was recently changed to reflect it can be taken every 6 hours as needed. Surveyor also identified a bottle of hydrocodone-acetaminophen 5mg-325mg oral tablets that expired on 10/8/24. During an interview, the patient reported he/she has not taken that medication for greater than 6 months. c. Skilled nurse visit note, dated 8/11/25, signed completed by Staff C, LPN, failed to identify care coordination with the case manager regarding the need for an updated verbal order for oxycodone-acetaminophen and failed to remove the hydrocodone-acetaminophen from the medication profile as the prescription expired and the patient reported no longer using the medication. d. Review of the clinical record lacked documentation of an updated verbal order for the medication oxycodone-acetaminophen. The agency failed to include verbal orders for all medications required by the patient and failed to maintain a current medication profile. The above findings were reviewed with the agency President, Administrator, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead RN.”

“HH aide training program topics CFR(s): 484.80(b)(3) A home health aide training program must address each of the following subject areas: (i) Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff. (ii) Observation, reporting, and documentation of patient status and the care or service furnished. (iii) Reading and recording temperature, pulse, and respiration. (iv) Basic infection prevention and control procedures. (v) Basic elements of body functioning and changes in body function that must be reported to an aide’s supervisor. (vi) Maintenance of a clean, safe, and healthy environment. (vii) Recognizing emergencies and the knowledge of instituting emergency procedures and their application. (viii) The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property. (ix) Appropriate and safe techniques in performing personal hygiene and grooming tasks that include -- (A) Bed bath; (B) Sponge, tub, and shower bath; (C) Hair shampooing in sink, tub, and bed; (D) Nail and skin care; (E) Oral hygiene; (F) Toileting and elimination; (x) Safe transfer techniques and ambulation; (xi) Normal range of motion and positioning; (xii) Adequate nutrition and fluid intake; (xiii) Recognizing and reporting changes in skin condition; and (xiv) Any other task that the HHA may choose to have an aide perform as permitted under state law. (xv) The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section. This Element 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 3 of 4 sampled home health aides (Staff I, Staff J and Staff K), assigned to perform tasks requiring extra skills exceeding the level of basic home health skills for 2 of 3 sampled patients (Patients #1 and #2) with home health aide services, had documented evidence of competency by a registered nurse in the assigned task area prior to independently performing the task with a patient. The agency provided home health aide services to 39 patients at the time of the survey and employed 7 home health aides. Failure to ensure home health aides successfully complete a competency evaluation in any assigned extra skills which exceed the level of basic home health aide skills placed the patients at risk to receive inadequate or unsafe home health aide services. 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 to be performed. According to the agency policy titled Competency Program, revised 11/2024, the organization will clearly identify and define the skills, which are essential to observe for the determination of competence for each job category. After completion of orientation, competency will be monitored annually thereafter as part of the annual performance field evaluation process. Competency will also be monitored when personnel are performing a new procedure or using a piece of equipment for the first time. During an interview on 8/12/25 at 3:45 PM, the Administrator reported extra skills competencies are identified in each home health aide’s personnel file. 1.Patient #1 had a start of care date of 4/10/23. Clinical record review revealed: a. The aide care plan included Registered Nurse (RN) instructions to the aide to apply orthotic brace to left foot after shower every visit. b. Review of the clinical record showed Staff J and Staff K, Home Health Aides, provided aide services independently for Patient #1. c. Staff J, Home Health Aide, had a hire date of 12/4/23. Staff J’s personnel file lacked documentation a RN had observed Staff J competently perform the task apply orthotic brace. d. Staff K, Home Health Aide, had a hire date of 6/30/22. Staff K’s personnel file lacked documentation a RN had observed Staff K competently perform the task apply orthotic brace. 2.Patient #2 had a start of care date of 8/14/20. Clinical record review revealed: a. The aide care plan included RN instructions to the aide to apply topical ointment and to apply a simple dressing every visit. b. Review of the clinical record showed Staff I, Home Health Aide, provided aide services independently for Patient #2. c. Staff I, Home Health Aide, had a hire date of 8/5/25. Staff I’s personnel file lacked documentation a RN had observed Staff I competently perform the tasks apply topical ointment and apply a simple dressing. 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 agency President, Administrator, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead RN.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on staff interview, clinical record review and policy review, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 2 sampled patients (Patient #1) with a home observation visit who received hands on personal care services in conjunction with a skilled service provision. The agency reported 39 patients who received home health aide services with every 14 day supervision. Failure to supervise home health aide services at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency’s policy titled Responsibilities/Supervision of Clinical Services, revised 11/2024, home health aide supervisory visits will be conducted on-site at least every 14 days by skilled personnel. Supervisory visits can be made in conjunction with the home health aide or in his/her absence. During an interview on 8/12/25 at 9:00 AM, the Clinical Manager stated aide supervision is done every 14 days and it is documented in a form pulled into the nursing visit. Patient #1 had a start of care date of 4/10/23. Clinical record review revealed: a. The Plans of Care (POC), dated 5/29/25 to 7/27/25 and 7/28/25 to 9/25/25, identified the patient had a diagnosis of Chronic Obstructive Pulmonary Disease with exacerbation and included physician orders for skilled nursing and home health aide services. b. The skilled nurse recertification visit note, dated 7/25/25, completed by Staff H, Registered Nurse (RN), included documentation of home health aide supervision. c. As of 8/11/25, home health aide supervision had not been completed again (3 days late). The agency failed to provide home health aide supervision every 14 days. The above findings were reviewed with the agency President, Administrator, Clinical Manager, QAPI Coordinator and Corporate Clinical Lead RN.”