Every finding on record at Berlin Visiting Nurse Association

Unannounced visits were concluded at Berlin VNA on 9/3/25 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

An unannounced visit concluded at Berlin VNA on 9/3/25 for the purpose of state re-licensure and recertification. The agency was in substantial compliance with the Code of Federal Regulations at §484.00, Condition of Participation for Home Health Agencies, standard level deficiencies were identified.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on review of the clinical records and interview with agency personnel for one of seven patients (Patient #4) in the survey sample, the agency nurses failed to provide services per the physician orders and patient's plan of care. The findings include: Patient #4 had a start of care date of 8/06/25 and diagnoses that included cervicalgia, left hemiplegia following a cerebral infarct and heart failure. The physician's orders dated 8/06/25 included nursing services once weekly for assessments, home health aide services, physical therapy and occupational therapy services. Review of the clinical record from 8/06/25 to 9/02/25 identified a missed visit note by Registered Nurse/RN #1, dated 8/12/25 (Tuesday) identifying that the patient refused the scheduled nursing visit due to other appointments scheduled for the day, and indicated that the visit would be rescheduled for later in the week. Interview and review of RN #1’s documentation dated 8/12/25 with the Interim Administrator on 9/03/25 at 12:15 PM identified a weekly visit was scheduled for 8/12/25 but the patient cancelled the visit, due to other disciplines visiting the same day, and indicated that another visit should have been scheduled in the same Medicare week, in accordance with physician’s orders and the agency expectations. Although requested, there was no policy to review.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on review of the clinical record and interview with agency personnel for one of seven patients (Patient #4) in the survey sample, the Governing Body failed to develop policies for missed visits and/or the provision of services in the plan of care. The findings include: Patient #4 had a start of care date of 8/06/25 and diagnoses that included cervicalgia, left hemiplegia following a cerebral infarct and heart failure. The physician's orders dated 8/06/25 included nursing services once weekly for assessments, home health aide services, physical therapy and occupational therapy services. Review of the clinical record from 8/06/25 to 9/02/25 identified a missed visit note by Registered Nurse/RN #1, dated 8/12/25 (Tuesday) identifying that the patient refused the nursing visit due to other appointments scheduled for the day and indicated that the visit would be rescheduled for later in the week. Interview and review of RN #1’s documentation dated 8/12/25 with the Interim Administrator on 9/03/25 at 12:15 PM identified the weekly visit was scheduled for 8/12/25, but the patient cancelled the visit due to other disciplines visiting the same day, and indicated that another visit should have been scheduled in the same Medicare week in accordance with physician’s orders and agency expectations. Although requested, there was no policy to review.

An unannounced visit was concluded at Berlin Visiting Nurse Agency on 9/14/2022 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded at Berlin Visiting Nurse Association on 9/14/2022 for the purpose of recertification. Standard level deficiences were identified.

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 observations, review of the clinical record, staff interviews and review of agency polices for one of two patients (Patient # 2) who required wound care, the agency nurses failed to follow the agency wound care policy. The finding includes: Patient #2 had a start of care date of 3/28/22 and diagnoses that included pressure ulcer of the right heel (unstageable), peripheral vascular disease, hyperlipidemia, obesity, hypertension, and lymphedema. The physicians order for the certification period of 7/24/22- 9/23/22 included nursing services for assessment for signs and symptoms of wound infection, monitoring wound healing and to report complications to licensed provider. Interview and review of the clinical record with supervisor of clinical services (SCS) on 9/13/22 at 9:30 AM, identified the agency nurses failed to document weekly wound measurements for the following skilled nursing visits, and failed to follow agency policy for weekly wound assessment and measurement requirement. RN #1: 7/2/22, and 8/5/22. RN #2: 7/29/22, 7/31/22, 8/3/22, 8/7/22, and 8/31/22. RN #3: 8/12/22, and 8/26/22 RN #4: 8/24/22, 8/28/22 and 9/2/22 RN #5: 8/10/22 Review of agency Wound Assessment and Measurement Policy directs that on patient's start of care visit, wounds will be initially measured, length, by width, by depth, then followed by weekly measurements of all wounds with documention completed within the patient's medical record.