Public home-health agencies among those cited for no-show workers and poor-quality care

By: - December 7, 2022 3:24 pm

In March, state officials cited Burlington’s Nurse at Home agency with 18 regulatory violations, and barred the agency from providing basic-skills competency training and from evaluating home-health aides’ competency for two years. The agency serves roughly 139 patients with at-home care. (Photo via Google Earth)

Thirty-four of Iowa’s 136 home-health agencies were inspected by the state this year, with five of them cited for 10 or more violations.

At four of the 34 agencies, the violations were serious enough that the agency and its registered nurses were prohibited from providing any basic-skills training to home-health aides and barred from evaluating the aides’ competency for two years.

Eight of the agencies cited for violations this year are run by county public health agencies.

The home-health agency that compiled the worst record of performance in Iowa during 2022 was Nurse at Home in Burlington. The federal Centers for Medicare and Medicaid Services gave the agency a one and one-half star quality rating, and state officials cited the agency for 18 violations.

One of those violations was related to Nurse at Home’s failure to investigate an aide who reportedly borrowed $180 from a patient and didn’t pay it back.

One Nurse at Home patient told inspectors that aides didn’t come to their house “for a whole week because they didn’t have a nurse. So that was tough, but we made it work.” Another patient complained, “They have a lot of no-shows, they don’t call or they don’t have anyone to send.”

For a more detailed look at all of Iowa’s home-health agencies, including those that weren’t inspected in 2022, visit CMS’ Care Compare website or the Iowa Department of Inspections and Appeals website.

Here’s a summary of the inspectors’ findings at each of the 34 agencies visited by the state in 2022, listed in alphabetical order. Along with the inspectors’ findings, you’ll find CMS’ ratings, which are based on a scale of one to five stars, for each agency. (Some ratings are listed as ‘not available’ due to insufficient data on which to base a rating.)

Advanced Home Health Care, Burlington – Quality rating: Three stars. Patient survey rating: Four stars. The agency was cited for three violations in October 2022: failure to review patients’ current medications; failure to deliver care only as ordered by a physician in three of the 10 cases that were reviewed; and failure to include all of the necessary elements in patient-care plans in five of the 10 cases reviewed by inspectors.

Angels Care Home Health of Iowa, Council Bluffs – Quality rating: Three stars. Patient survey rating: Four stars. The agency had 476 patients in January 2022 when it was cited for five violations: failure to review all current medications in 14 of the 17 cases that were reviewed; failure to implement a complete plan of care in 11 of 17 of the cases that were reviewed; failure to provide physician-ordered services in seven of the 17 cases that were reviewed; failure to communicate and coordinate patient care services with physicians in eight of the 17 cases that were reviewed; and failure to ensure home-health aides provided care only as ordered by a physician in three of the four cases that were reviewed.

Angels Care Home Health of Iowa, Des Moines – Quality rating: Three and one-half stars. Patient survey rating: Two stars. Zero violations found during a July inspection.

Aveanna Healthcare, Sioux City – Quality rating: Three stars. Patient survey rating: Two stars. In July, the agency was cited for two violations: failure to follow a physician’s plan of care by not providing patients with the required number of hours of care; and failure to provide services as ordered by a physician by not completing wound assessments.

Aveanna Healthcare, Council Bluffs – Quality rating: Three and one-half stars. Patient survey rating: Three stars. The agency had 89 patients in July when it was cited for two violations: failure to ensure the accurate completion of all tasks in two of the five patient-care plans reviewed; and failure to provide physician-ordered treatment in two of the five cases reviewed.

Aveanna Healthcare, West Des Moines – Quality rating: Four stars. Patient survey rating: Two stars. The agency had 124 patients in July when it was cited for four violations: failure to follow the patients’ plan of care in seven out of eight cases reviewed, with several  patients not receiving the physician-ordered skilled nursing care on days when it was ordered; failure to  ensure the accurate completion of all elements in each patient’s plan of care; failure to update patients’ care plans with new physician orders; and failure to provide physician-ordered treatment. (An affiliated Aveanna Healthcare home-health agency, also in West Des Moines, was cited for one violation in July: failure to provide physician-ordered visits by a home-health aide.)

Aveanna Healthcare, Cedar Rapids – Quality rating: Three and one-half stars. Patient survey rating: Three stars. The agency had 166 patients in July when it was cited for two violations: failure to provide all of the required visits to patients in two out of three cases reviewed; and failure to provide medications or treatments as ordered by the physician in one out of three cases reviewed.

Aveanna Healthcare, Davenport – Quality rating: Three and one-half stars. Patient survey rating: Not available. Zero violations were cited during a July visit.

Buena Vista County Public Health, Storm Lake – Quality rating: Two stars. Patient survey rating: Not available. The agency had 50 patients in March when it was cited for six violations: failure to have a registered nurse assess patients within 48 hours of admission, with one patient not receiving an initial assessment for 10 days; failure to adequately review all patient medications in four out of seven cases reviewed; failure to devise a complete plan of care for patients; failure to ensure a registered nurse provided complete patient-specific written instructions to home-health aides; failure to assess wounds when necessary; and failure to send patient-care summaries to other medical providers when a patient is transferred elsewhere from the agency.

Caregivers Home Health, Chariton – Quality rating: Two and one-half stars. Patient survey rating: Four stars. The agency had 206 patients in February when it was cited for eight violations, including: incomplete patient-care plans in all of the four cases that were reviewed; failure to coordinate the delivery of care; failure to complete an interdisciplinary assessment of all patients; failure to provide the services outlined in each patient’s plan of care; failure to ensure that six out of the 11 home-health aides whose files were reviewed had successfully completed a competency evaluation; failure to ensure that a registered nurse provided home-health aides with individualized instructions on patient care; and the repeated failure to ensure that home-health aides reported any patient concerns, including low blood pressure, to a registered nurse.

Carroll Area Nursing Services, Carroll – Quality rating: Four stars. Patient survey rating: Four stars. The agency had 251 patients in February when it was cited for nine violations, a relatively high number. The violations included failure to review all patient medications in 11 of 13 cases that were reviewed; failure to devise complete plan of care for patients in 10 of 13 cases that were reviewed; failure to promptly alert a physician of changes in patient conditions in each of the two cases that were reviewed; failure to comply with infection-control guidelines; failure to conduct adequate interdisciplinary assessments of all patients; failure to provide the services outlined in each patient’s plan of care in four of the seven cases that were reviewed; failure to ensure that a registered nurse provided home-health aides with individualized instructions on patient care in four of eight cases that were reviewed; and failure to include all required elements in patients’ clinical record.

Cerro Gordo County Department of Public Health, Mason City – Quality rating: Three stars. Patient survey rating: Five stars. In February, the agency was cited for five violations, including inadequate patient-care plans in six of the seven cases that were reviewed; failure to promptly alert a physician to changes in patient conditions in both of two cases that were reviewed; inadequate infection control; failure to provide the services outlined in patients’ care plans in four of the seven cases that were reviewed; and failure to include the clinical record current and accurate documentation of medical interventions.

Chickasaw County Public Health & Home Care Services, New Hampton – Quality rating: Two stars. Patient survey rating: Not available. The agency had 59 patients in October when it was cited for seven regulatory violations, including failure to complete timely comprehensive assessments of residents after they’ve been hospitalized; failure to include wound care in patients’ overall care plans; failure to assess wounds as ordered by a physician; failure to comply with infection-control requirements; and failure to ensure that a registered nurse provided home-health aides with patient-specific instructions.

Community Health Services, Cresco – Quality rating: Two and one-half stars. Patient survey rating: Five stars. The agency had 32 patients in October when it was cited for five violations, including failure to ensure complete patient-care plans were devised in five of the eight cases that were reviewed; failure to provide medications and treatment as ordered by a physician; failure to promptly alert a physician to a patient’s changing condition; and failure to ensure that a registered nurse provided home-health aides with patient-specific instructions in two of the six cases that were reviewed.

Family Care Solutions, Davenport – Quality rating: Not available. Patient survey rating: Not available. The agency had a total of 41 patients in June when it was cited for four regulatory violations, including: failure to devise complete care plans for patients in four of the seven cases that were reviewed; failure to update care plans with all new physician orders; failure to ensure that a registered nurse provided home-health aides with patient-specific instructions in three of the five  cases that were reviewed; and failure to ensure that home-health aides provided care in accordance with physicians’ orders.

Gateway Home Health (formerly Careage Home Care), Clarion – Quality rating: Three stars. Patient survey rating: Not available. In April, the agency was cited for 20 regulatory violations, an unusually high number. The agency was found to be not in compliance with Medicare regulations for home-health agencies, and so the agency and its registered nurses were barred from providing basic-skills competency training for two years and were prohibited from providing evaluations of home-health aides’ skills testing for two years. Among the problems cited by inspectors: failure to have procedures in place to notify state and local officials of homebound residents in the event of a natural disaster; failed to complete timely drug-regimen reviews  in 14 of 15 cases that were reviewed; failure to update patient-care assessments within 48 hours of a patient being transferred from a care facility or hospital; failure to create accurate and complete care plans in three of 10 cases that were reviewed; failure to update plans of care with new physician orders in all of the six cases that were reviewed; and failure to complete and send patient-care summaries to physicians within two days of a patient being transferred to an inpatient facility. In September, inspectors cited the agency for failing to conduct a drug-regimen review in all of the five cases that were reviewed.

Genesis Visiting Nurses Association, Bettendorf — Quality rating: Three stars. Patient survey rating: Four stars. In January, the agency had 802 patients and was cited for four regulatory violations, including: failure to devise complete patient-care plans in 10 of the 17 cases that were reviewed; failure to ensure that clinicians followed agency policies when assessing patients’ wounds; and failure to ensure skilled professionals provided care as ordered by physicians.

Good Samaritan Home Care, Indianola – Quality rating: Three and one-half stars. Patient survey rating: Not available. In February, the agency had 57 patients and was cited for 11 regulatory violations, an unusually high number. Among the problems: failure to complete a timely drug-regimen review in four of the eight cases that were reviewed; failure to update patients’ comprehensive assessments within 48 hours of them returning home from an inpatient facility; failure to follow plans of care in four of the seven cases that were reviewed; failure to devise complete patient-care plans in four of the seven cases that were reviewed; failure to provide physician-ordered medications, treatments or other services in one of the eight cases that were reviewed; failure to ensure home-health aides had successfully completed all of the required basic-skills competency evaluations; and failure to ensure that a registered nurse provided home-health aides with patient-specific instructions in two of the three cases that were reviewed.

Home Care Services of Boone County, Boone – Quality rating: Three and one-half stars. Patient survey rating: Four stars. In November, this agency had a total of 71 patients and was cited for five violations: failure to update a patient’s comprehensive assessment to include information on the patient’s current health status; failure to complete a review of patients’ drug regimen in three of the seven cases that were reviewed; failure to complete all elements of a patient’s care plan in four of the seven cases that were reviewed; failure to provide care and treatment as ordered by physicians in two the seven cases that were reviewed; and failure to adhere to infection-control protocols.

Home Sweet Home Care, Atlantic – Quality rating: Not available. Patient survey rating: Not available. In June, this agency was cited for 19 regulatory violations, an unusually high number. Several of the violations were tied to the agency’s failure to devise an adequate emergency preparedness plan for use in the event of a natural disaster. Among the other problems: a failure to adequately assess each patient’s medications in three of the seven cases that were reviewed; failure to follow patients’ care plans in six of the seven cases reviewed; failure to ensure care plans were complete in four of the seven cases reviewed; failure to follow physicians’ orders or care-plan directives in three of the seven cases reviewed; failure to follow infection-control protocols; failure to ensure the home-health aides successfully completed competency testing in all of the five cases that were reviewed by inspectors; failure to ensure home-health aides provided care as ordered by physicians; and failure to complete and send patient-care summaries to physicians within two days of a patient being transferred to an inpatient facility.

Iowa Home Care, Ottumwa – Quality rating: One and one-half stars. Patient survey rating: Three stars. In January, the agency had a total of 190 patients and was cited for 10 regulatory violations, an unusually high number. Inspectors reported that the agency’s chief of organizational performance said the agency had stopped “admitting new patients due to the fines and being unsure if the office would be kept open. The agency was not going to hire any new employees due to the issue of fines.” (It’s not clear what fines were being referenced, as none were imposed by the state.)

Among the problems cited by the inspectors: failure to ensure initial visits with patients occurred within 48 hours of a referral; failure to complete accurate drug regimen reviews; failure to accurately complete a plan of care in five of the 17 cases that were reviewed; failure to provide medications and treatment as ordered by a physician in four of the 17 cases that were reviewed; failure to report to a physician any changes in clinical findings in three of 17 cases that were reviewed; and failure to coordinate patient care in four of 17 cases reviewed.

In August, inspectors returned and cited the agency for three additional violations: failure to follow a patient’s plan of care by not providing the physician-recommended number of home-care visits; failure to keep a patient’s plan of care up to date with new physician orders; and failure to provide care as ordered by a physician.

Iowa Home Care, West Des Moines – Quality rating: Two stars. Patient survey rating: Three stars. Zero violations cited during an August inspection.

Johnson County Visiting Nurses Association, Iowa City – Quality rating: Two and one-half stars. Patient survey rating: Not available. In January, the agency was cited for two regulatory violations: failure to follow a patient’s plan of care by neglecting to provide the required home-care visits and physical therapy; and failure to accurately report a patient’s medications in the plan of care.

Nurse at Home, Burlington – Quality rating: One and one-half stars. Patient survey rating: Not available. In March, the agency had 139 patients and was cited for 18 regulatory violations, an unusually high number. Inspectors concluded the agency was not in compliance with the conditions of participation in the Medicare program and so the agency and its registered nurses were barred from providing basic-skills competency training to others and were prohibited from providing evaluations of home-health aides’ competency for two years.

Several of the violations were related to a lack of emergency preparedness. Among the others: failure to review patients’ drug regimen as required in all of the nine cases that were reviewed; failure to follow patients’ physician-ordered plan of care in five of the 11 cases that were reviewed; failure to inform patients’ physicians of missed appointments with patients; failure to ensure the patients’ plan of care was accurate and complete in six of the nine cases reviewed; failure to ensure home care aides received the required competency testing; failure to ensure all home-health aides are assigned to a specific patient by a registered nurse; failure to ensure all aides provide services as ordered by physicians in six of eight cases that were reviewed; failure to provide aides with individualized and specific patient care instructions from a registered nurse in seven of eight cases that were reviewed; failure to accurately complete patient medical records in a timely fashion, with some entries being improperly backdated; and failure to complete the required background checks on employees in two out of four cases that were reviewed.

Inspectors cited several examples of Nurse at Home records explaining missed appointments by indicating the patients had refused care when staff arrived at their homes — a claim the patients denied. One patient told inspectors the agency didn’t always send someone to his or her home because they seemed to be short-staffed. “Once they didn’t come for a whole week because they didn’t have a nurse,” the patient said. “So that was tough, but we made it work.”

Another patient complained of seeing a nurse taking a picture of herself outside her door and then leaving without attempting to enter — apparently in an effort to show she had tried to deliver services that day. A third patient told inspectors, “The aides do a good job, but they leave, and the agency has a hard time replacing them. They have a lot of no-shows, they don’t call or they don’t have anyone to send. We never refuse care.”

The agency was also cited for a failure to investigate complaints and failure to take action to prevent the reoccurrence of violations. One of the complaints against Nurse at Home came from the sibling of a client who said a former home-health aide owed the client money. The sibling said that in September 2021, the worker was upset and sitting on the patient’s living room floor saying she had no money to buy gas or food and was unable to feed her children. The patient and her sibling then loaned the worker $100 in cash and gave her a Walmart gift card with an $80 balance. The aide said she would pay back the $180 but never did. The patient’s sibling reported the matter to a registered nurse at the agency and eventually went to the Nurse at Home office to explain the situation and get the aide’s contact information.

Nurse at Home’s clinical manager told inspectors the agency never investigated the matter, in part because the aide no longer worked there and the patient was no longer a client. The clinical manager also indicated she felt the loan was a “personal transaction” that didn’t involve the agency.

In June, inspectors returned and cited Nurse at Home for three additional violations: failure to accurately complete a review of patients’ drug regimen in three of eight cases that were reviewed; failure to follow the plan of care established by a physician; and failure to accurately complete all elements of patients’ care plans in six of 10 cases that were reviewed.

Regional Medical Center Home Care, Manchester – Quality rating: Two and one-half stars. Patient survey rating: Four stars. In March, the agency had 86 patients and was cited for one regulatory violation. State inspectors alleged the agency failed to maintain consistent policies and procedures related to employees who were not vaccinated against COVID- 19. The agency’s policies for dealing with unvaccinated workers directly conflicted with Regional Medical Center’s written policies.

Southwest Iowa Home Health Services, Hamburg – Quality rating: Not available. Patient survey rating: Not available. In May, the agency had 18 patients and was cited for seven violations, some of which were tied to emergency preparedness. Among the other violations: failure to spot discrepancies in patients’ drug regimen; failure to ensure home-health aides had all of the required competency evaluations; failure to ensure nurses provided aides with individualized, patient-specific instructions for each patient; and failure to give other medical providers a summary of clients’ home care once those clients are transferred to an inpatient setting.

Sunny Brook Home Care, Fairfield – Quality rating: Not available. Patient survey rating: Two stars. In May, the agency had 173 patients and was cited for one violation: failure to ensure that all hard-copy patient records were maintained in a secure manner and were uploaded to the electronic medical record in a timely fashion.

Tama County Public Health & Home Care, Toledo – Quality rating: Three and one-half stars. Patient survey rating: Not available. In January, the agency had 51 patients and was cited for four violations: failure to ensure patients were informed of charges for services that may not be covered by Medicare or Medicaid; failure to complete a drug regimen review for three of the eight cases that were reviewed; failure to ensure aides provided care to patients only as ordered by the physician; and failure to ensure clinical records included current information related to therapy services.

Waterloo Visiting Nurses Association, Waterloo – Quality rating: One and one-half stars. Patient survey rating: Not available. In February, the agency had 131 patients and was cited for three violations. At that time, the agency was operating under a recently imposed order that prohibited the agency and its registered nurses from providing basic-skills training to aides or evaluating aides’ competency for a period of two years. That order stemmed from two separate December 2021 inspections that resulted in the agency being cited for a total of 28 violations. The February 2022 violations were for failure to assess each patient’s medications for duplications, side effects, ineffectiveness, potential interactions, etc.; failure to update a patient’s assessment within 48 hours of resuming care after a hospitalization; and failure to update patient care plans with new physician orders.

Wel-Home Health, Red Oak – Quality rating: Two and one-half stars. Patient survey rating: Five stars. In June the agency had 104 patients and was cited for nine regulatory violations, a relatively high number. Among the violations: lack of emergency preparedness; failure to assess each patient’s medications for duplications, side effects, ineffectiveness, potential interactions, etc.; failure to follow patients’ care plans as directed by a physician in three of seven cases that were reviewed; failure to  ensure the accurate completion of patient-care plans in four of seven cases that were reviewed; failure to perform interdisciplinary assessments of patients; failure to ensure aides were competent in all required skills; failure to ensure aides provided care only as directed by a physician; failure to ensure the supervision of home-health aides by registered nurses; and failure to send hospitals a summary of patient care to accompany the clients who are transferred to hospitals.

Wel-Home Health, Sergeant Bluff – Quality rating: Not available. Patient survey rating: Not available. Zero violations were cited during an August inspection.

WesleyLife Home Health, Urbandale – Quality rating: Three stars. Patient survey rating: Three stars. In February, the agency had 536 patients and was cited five violations, including: lack of emergency preparedness; failure to follow a physician-ordered plan of care in two of the 17 cases that were reviewed; failure to accurately complete all elements of patient-care plans in six of the 17 cases that were reviewed; failure to ensure that skilled professionals provided care as ordered by a physician in four of the 17 cases that were reviewed; and failure to ensure aides provided care only as ordered by a physician in three of the six cases that were reviewed.

Winnebago County Public Health Nurses, Forest City – Quality rating: One and one-half stars. Patient survey rating: Not available. In February, the agency had 86 patients and was cited for three violations: failure to follow a physician-ordered plan of care in six of seven cases that were reviewed; failure to accurately complete all elements of patients’ care plans in two out of three cases that were reviewed; and failure to complete an interdisciplinary assessment of all patients.

Winneshiek County Public Health Nurses, Decorah – Quality rating: Not available. Patient survey rating: Not available. In April, the agency had 49 patients and was cited for eight violations and was found to be out of compliance with the conditions for participating in Medicare. As a result, the agency and its registered nurses were prohibited from providing basic-skills training to aides or evaluating aides’ competency for a period of two years.

Among the violations cited at that time: failure to ensure patients were admitted with a reasonable expectation that their medical needs could be met in their homes; failure to ensure all treatments required by the patients were included in their care plan; failure to provide treatments only as ordered by the physician; failure to provide education to contracted staffers on COVID-19 mitigation; failure to follow state pharmaceutical laws by storing patient medications in the agency office; and a failure by the agency’s governing body, which is the Winneshiek County Board of Health, to oversee the day-to-day operation of the agency. During a revisit in May, zero violations were cited.

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Clark Kauffman
Clark Kauffman

Deputy Editor Clark Kauffman has worked during the past 30 years as both an investigative reporter and editorial writer at two of Iowa’s largest newspapers, the Des Moines Register and the Quad-City Times. He has won numerous state and national awards for reporting and editorial writing. His 2004 series on prosecutorial misconduct in Iowa was named a finalist for the Pulitzer Prize for Investigative Reporting. From October 2018 through November 2019, Kauffman was an assistant ombudsman for the Iowa Office of Ombudsman, an agency that investigates citizens’ complaints of wrongdoing within state and local government agencies.

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