Every finding on record at Berkshire Medical Center, Inc.

A Recertification survey was conducted at Berkshire Visiting Nurse Association on 1/24/23 through 1/27/23 for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Berkshire Visiting Nurse Association on 1/24/23 through 1/27/23, to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff conformed with the Physician's order for two Patients (#5 and #14), out of a total sample of 17 patients. Specifically, (1) for Patient #5 the Agency staff failed to provide Occupational Therapy (OT) services as ordered, and (2) for Patient #14, the Agency staff failed to provide Skilled Nurse (SN) services, as ordered. Findings include: 2. For Patient #14, the Agency failed to ensure its staff provided a SN visit, as ordered. Patient #14 was admitted to the Agency in October 2022 with a diagnosis of chronic pain. Review of the Home Health Certification and Plan of Care for certification period 10/22/22 through 12/10/22 indicated a Physician order: -SN visit two times a week for two weeks. Review of the clinical record indicated only one SN visit was provided for the week of 10/9/22 through 10/15/22 and not two, as ordered. During an interview on 1/26/23 at 3:45 P.M., after reviewing the clinical record, the Quality Assurance Nurse said the plan of care was not followed and two SN visits were not provided to Patient #14 for the week of 10/9/22 through 10/15/22, as required. Review of the Agency's policy titled, Plan of Care, undated, indicated the following: -Home health services and care plan development are furnished under Physician supervision, with direct care and planning by qualified home health services. -A patient's plan of care is written by licensed home health personnel based on the Physician's orders, written or verbal, utilizing the 485 format (plan of care for home health agencies). -If a Physician refers a client (patient) under a plan of care that cannot be completed until after an evaluation visit, the physician is consulted to approve any additions or modifications in the original plan of care. 1. Patient #5 was admitted to the agency in December 2022 with a diagnosis of Diabetes Mellitus (a group of diseases that results in too much sugar in the blood, high blood sugar). Review of the Physician's orders for certification period 12/8/22 through 2/5/22, indicated the following: -OT evaluation and treatment. Review of the clinical record indicated an OT evaluation and treatment were not provided as ordered. During an interview on 1/26/23 at 1:15 P.M., after reviewing the clinical record, the Quality Assurance Nurse said that the OT evaluation and treatment were not provided, as ordered by the Physician.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff provided Home Health Aide (HHA) services as ordered by the Physician, as indicated in the plan of care for one Patient (#15), out of a total sample of 17 patients. Findings include: Patient #15 was admitted to the Agency in October 2022 with a diagnosis of Hypertensive Heart Disease (heart problems that occur because of high blood pressure that is present over a long time). Review of the Physician's order for certification period 10/6/22 through 12/4/22, indicated the following: -As of 10/9/22, HHA services once a week for three weeks. Review of the clinical record indicated the Patient received HHA services on 10/14/22, 10/17/22, 10/24/22, 10/31/22, 11/7/22 and 11/14/22. During an interview on 1/27/23 at 11:40 A.M., after reviewing the clinical record, the Quality Assurance Nurse said there was not a Physician's order for Patient #15 to have received HHA services on 10/31/22, 11/7/22 and 11/14/22. She said the nursing staff did not get a Physician order, as required, to extend the HHA services for three additional weeks.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff notified the Physician when the plan of care was not followed for three Patients (#6, #14 and #16), out of a total sample of 17 patients. Specifically, the plan of care was not followed for: 1.) one missed Skilled Nurse Visit (SNV) for Patient #6, 2.) one missed SNV for Patient #14 and 3.) a. one missed SNV and b. one missed Speech Therapy (ST) visit for Patient #16. Findings include: Review of the facility policy titled, Plan of Care, undated, included, not limited to: -Any physical changes or alteration in response to care or changes in the condition of the patient will be reported to the physician as soon as possible via telephone or fax to update or amend the orders. Any changes in patient, plan of care and reviews with the physician will be documented in the patient's record by the licensed home health staff. 1. For Patient #6, the Physician was not notified of a missed SNV. Patient #6 was admitted to the Agency in December 2022 with a diagnosis of acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood). Review of the Home Health Certification and Plan of Care for certification period 12/22/22 through 2/19/23 indicated a Physician order: -1/1/23, SNV one time a week for two weeks Review of the clinical record indicated for the week of 1/1/23 through 1/7/23, a SNV was canceled due to Patient #6 having a Primary Care Physician (PCP) visit on 1/6/23. Further review of the clinical record did not contain any documentation that the Physician had been notified of the missed SNV. During an interview on 1/26/23 at 11:00 A.M., after reviewing the clinical record, the Quality Assurance Nurse said the Physician was not notified of the missed SNV on 1/6/23, as required. 2. For Patient #14, the Physician was not notified of a missed SNV. Patient #14 was admitted to the Agency in October 2022 with a diagnosis of chronic pain. Review of the Home Health Certification and Plan of Care for certification period 10/12/22 through 12/10/22 indicated a Physician order: -10/12/22, SNV two times a week for two weeks. Review of the clinical record indicated one SNV occurred for the week of 10/9/22 through 10/15/22. Further review of the medical record did not contain any documentation that the Physician was notified of the missed SNV. During an interview on 1/26/23 at 3:45 P.M., after reviewing the clinical record, the Quality Assurance Nurse said the Physician was not notified of a missed SNV for the week of 10/9/22 through 10/15/22, as required. 3. For Patient #16, the Physician was not notified of a. one missed SNV and b. one missed ST visit. Patient #16 was admitted to the Agency in April 2022 with a diagnosis of aftercare following surgery for a neoplasm (a new and abnormal growth of tissue in some part of the body). Review of the Home Health Certification and Plan of Care for certification period 6/12/22 through 8/10/22 indicated Physician orders: -6/12/22, SNV two times a week for two weeks, -6/12/22, ST visit once a week for four weeks. a. Review of the clinical record indicated only one SNV was provided for the week of 6/19/22 through 6/25/22 and not two, as ordered. Further review of the clinical record did not contain any documentation that the Physician had been notified of the missed SNV. During an interview on 1/27/23 at 11:30 A.M., after reviewing the clinical record, the Quality Assurance Nurse said the Physician was not notified of the missed SNV, as required. b. Review of the clinical record included documentation that the ST visit scheduled for 7/27/22 was canceled by Patient #16. There was no documentation to indicate the Physician had been notified of the canceled ST visit. During an interview on 1/27/23 at 12:10 P.M., after reviewing the clinical record, the Quality Assurance Nurse said the Physician was not notified of the canceled ST visit for 7/27/22, as required.