Every finding on record at Brockton VNA

A Recertification survey was conducted at Brockton VNA, located at 500 Belmont Street, Brockton, MA 02301, on 3/3/26, 3/4/26, and 3/5/26 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 Brockton VNA, located at 500 Belmont Street, Brockton, MA 02301, on 3/3/26, 3/4/26, and 3/5/26 to determine compliance with 42 CFR Part 484 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.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure the Notice of Medicare Non-Coverage (NOMNC-an official Centers for Medicare and Medicaid Services (CMS) form that informs beneficiaries when their Medicare-covered skilled services, home health or outpatient rehabilitation services are ending and explains the right to appeal the decision) was provided prior to discharge for 3 of 5 applicable patients (#13, #14, #16), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled “Notice of Medicare/Medicare Advantage Provider Non-Coverage”, with revised date of January 2019, indicated the following: *Notice of Medicare/Medicare Advantage Provider Non-Coverage must be validly delivered two days or before next to the last professional home visit before the effective termination of service date. 1. Patient #13 was admitted to the agency in September 2025 with a diagnosis of hypertensive heart disease and required home care services. Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 9/5/25 through 11/3/25, indicated the following: -Skilled Nursing (SN): 1 time a week for 9 weeks. -Physical Therapy Services (PT): 1 time a week for 1 week (9/9/25). -PT: 1 to 2 times a week for 8 weeks (9/14/25). -PT: 1 time a week for 2 weeks (10/26/25). Review of the clinical record indicated Patient #13's goals were met and was discharged from the agency on 10/27/25. Further review of the clinical record indicated the NOMNC notice was provided and signed by the patient on 10/27/25, not 2 days prior to discharge as required. 2. Patient #14 was admitted to the agency in October 2025 with a diagnosis of chronic obstructive pulmonary disease (COPD) and required home care services. Review of the physician ordered Home Health Certification and POC for certification period 10/1/25 through 11/29/25, indicated the following: -SN: 1 time a week for 8 weeks. Review of the clinical record indicated Patient #14's goals were met and was discharged from the agency on 11/25/25. Further review of the clinical record indicated the NOMNC notice was provided and signed by the patient on 11/25/25, not 2 days prior to discharge as required. 3. Patient #16 was admitted to the agency in January 2026 with a diagnosis of pressure ulcer of left heel and required home care services. Review of the physician ordered Home Health Certification and POC for certification period 1/30/26 through 3/30/26, indicated the following: -SN: 1 time a week for 1 week (1/30/26). -SN: 2-3 times a week for 9 weeks (2/1/26). -SN: 1 time a week for 6 weeks (2/15/26). Review of the clinical record indicated Patient #16's goals were met and was discharged from the agency on 2/27/26. Further review of the clinical record indicated the NOMNC notice was provided and signed by the patient on 2/27/26, not 2 days prior to discharge as required. During an interview on 3/5/26 at 11:30 A.M., the Administrator reviewed the clinical record for Patient’s #13, #14, and #16 and said the NOMNC was not provided timely as required.

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 record review, policy review and interview, the agency failed to ensure nursing services were provided under the supervision of a registered nurse (RN) for 3 patients (#6, #9 and #8), out of total sample of 7 patients, who received nursing services from a licensed practical nurse (LPN). 3. Patient #8 was admitted to the agency in February 2024 with a diagnosis of recurrent osteomyelitis (severe bone infection) and required skilled home care services. Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 12/10/25 through 2/7/26 indicated the following: -SN frequency: 2-3 times per week x 8 weeks (12/14/25). Review of the clinical record for dates of services between 1/4/26 through 2/5/26 indicated LPN visits were conducted on 1/4/26, 1/7/26, 1/9/26, 1/11/26, 1/16/26, 1/18/26, 1/23/26, 1/25/26, 1/28/26, 1/30/26, 2/1/26, and 2/4/26. Further review of these dates of service failed to include any documented RN supervisory visits. During an interview on 3/5/26 at 10:13 A.M., the Administrator said LPN supervisory visits were not completed every 30 days as required. Findings include: Review of the agency’s policy titled “Supervision of Licensed Practical Nurse (LPN) and Licensed Vocational Nurse (LVN)”, with revised date of September 2022, indicated the following: *Services furnished by an LPN or LVN will be furnished under the supervision of a qualified Registered Nurse (RN). Supervisory visits will occur every 30 days according to state law. *A visit to the patient’s home by RN every 30 days with or without the LPN or LVN present. 1.Patient #6 was admitted to the agency in December 2025 with a diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms and required home care services. Review of the physician ordered Home Health Certification and Plan of Care (POC) for certification period 12/19/25 through 2/16/26, indicated the following: -Skilled Nursing (SN) frequency: 1 time a week for 9 weeks. Review of the clinical record for dates of services between 12/19/25 through 2/16/26 indicated LPN visits were conducted on 1/14/26, 1/21/26, 1/28/26, 2/4/26, and 2/10/26. Further review of these dates of service failed to include any documented RN supervisory visits. 2.Patient #9 was admitted to the agency in December 2025 with a diagnosis of peripheral vascular disease and required home care services. Review of the physician ordered Home Health Certification and POC for certification period 12/26/25 through 2/23/26, indicated the following: -SN frequency: 2-3 times a week for 8 weeks (12/28/25) -SN frequency: 1-2 times a week for 6 weeks (1/18/26) Review of the physician ordered Home Health Certification and POC for certification period 2/24/26 through 4/26/26, indicated the following: -SN frequency: 1 time weekly for 1 week (2/24/26) -SN frequency: 2-3 times a week for 8 weeks (3/1/26) Review of the clinical record for dates of services between 1/4/26 through 3/3/26 indicated LPN visits were conducted on 1/9/26, 1/14/26, 1/16/26, 1/21/26,1/27/26, 1/30/26, 2/4/26, 2/6/26, 2/11/26, 2/13/26, 2/16/26, and 2/25/26. Further review of these dates of service failed to include any documented RN supervisory visits.

A Recertification survey was conducted at Brockton VNA on 3/15/23, 3/16/23, 3/17/23, 3/21/23, 3/22/23, and 3/23/23, 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 Brockton VNA on 3/15/23, 3/16/23, 3/17/23, 3/21/23, 3/22/23, and 3/23/23, 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.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and staff interview, the agency failed to ensure that for one patient Record Review (RR#2), of a total sample of 17 RRs, that Home Health Aide (HHA) services ordered in the Plan of Care (POC) were provided as ordered. Findings include: On 3/22/23, review of RR#2's medical record indicated a Start of Care (SOC) date of 12/8/22. Services listed in the Plan of Care (POC) for RR#2 included but was not limited to HHA visits. Review of the SOC Oasis (admission assessment) indicated that a HHA for 1-2 times per week for 1.5 hours duration was ordered on the POC on 12/8/22, but no HHA services were provided to the patient until 12/21/22. During an interview on 3/22/22 at 8:15 A.M., the Vice President (V.P.) of Excellence said that the HHA scheduler is required to respond to an added task (HHA) within 48 hours, and then follow up to ensure that the POC and visit frequency for the task are entered into the system so the service is scheduled and provided to the patient. She said that when she investigated the missed HHA visits with the scheduler, the scheduler said that the missed HHA visits were due to a lack of staffing.

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 for Home Health Aide (HHA) visits was not followed for one Patient (RR#2), out of a total sample of 17 patients. Findings include: On 3/22/23, review of RR#2's medical record indicated a Start of Care (SOC) date of 12/8/22. Services listed in the Plan of Care (POC) for RR#2 included a Home Health Aide (HHA) for 1-2 times per week for 1.5 hours duration. Record review indicated that although a HHA was ordered on the POC on 12/8/22, no HHA services were provided to the patient from 12/8/22 to 12/20/22. The first HHA visit was documented on 12/21/22. There was no documentation in the medical record to explain the delay in providing the patient with HHA services until 12/21/22 or indicating that they physician was notified of the delay in services. During an interview on 3/22/22 at 8:15 A.M., the Vice President (V.P.) of Excellence said that the HHA scheduler is required to respond to an added task (HHA) within 48 hours, and then follow up to ensure that the POC and visit frequency for the task are entered into the system so the service is scheduled and provided to the patient. She said that if the agency is unable to schedule the visit within 24 hours, a note should be entered in the medical record and the physician is to be notified of the delay, or omission, in providing the service. The V.P. of Excellence said that there was no note to the physician in the medical record and that the Agency failed to notify the physician when the HHA visits were not provided to the patient.