Every finding on record at Chesterfield Visiting Nurses Services Inc

An unannounced on-site Recertification survey was conducted at Suncrest Home Health from 08/20/25-08/22/25. The facility was found to be in compliance with the Condition of Participation under 42 CFR 484.102 for Emergency Preparedness.

An unannounced on-site Recertification Survey conducted at Suncrest Home Health from 08/20/25-08/22/25. The facility was in substantial compliance with the Conditions of Participation (CoP) at 42 CFR 484, Subparts A through C.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure the timely submission of OASIS (Outcome and Assessment Information Set) to IQIES (Internet Quality and Improvement and Evaluation System). The failure had the potential to affect all patients receiving services from the HHA who require evaluation and care. Findings included: Review of the agency's policy titled, "OASIS Data Capture, Transmission, Verification, Display and Reports," revised 03/01/21, revealed, "Purpose: To ensure proper OASIS data capture and transmission to state agencies and to ensure compliance with regulatory guidelines. 2. Transmittal of OASIS information a. At least monthly, Agency will electronically transmit . . . locked OASIS data to the state. All OASIS assessments completed must be transmitted within 30 days of the M0090 (assessment completion date) date. The agency's OASIS submission data since Quarter 3, 2024 was reviewed for timely transmission to IQIES. The data revealed late transmissions over the state’s threshold of 10.0% per quarter for four of the four quarters. A total of 12 assessments were transmitted late. This resulted in an error code of -3330 (late submission). During an interview on 08/22/25 at 11:20 AM, the interim Executive Director was asked about the delay in transmitting the OASIS information. The interim Executive Director stated they were unaware of the late OASIS submissions.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record reviews, interview, and policy review, the Home health Agency (HHA) failed to produce a discharge summary and failed to ensure a discharge summary had been sent to the physician within five days of the patient’s order for discharge for two of two patients reviewed, (Patient (P)8 and P9), for completion of the discharge summary. The HHA’s failure to complete a discharge summary places patients at risk for inappropriate continuum of care services. Findings included: Review of the Home Health Agency’s policy titled, "Patient Discharge/Transfer Process," with a review date of 10/01/23, directed staff, ". . . A discharge summary is to include admission and discharge dates, reason for admission to home health, reason for discharge, services provided, progress toward goals, patient’s discharge goals of care, patient’s treatment preferences, a list of community resources or referrals made, along with a current medication list is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 business days of patient's discharge . . ." 1. Review of P8’s Electronic Medical Record (EMR) under the orders tab revealed an admission date of 05/27/25 with diagnoses including multiple rib fractures, fractured vertebrae, and a broken foot. The physician’s orders included Physical Therapy one time a week for four weeks. P8 was discharged from the HHA on 07/25/25. Review of P8's EMR revealed no discharge summary. 2. Review of P9’s Electronic Medical Record (EMR) under the orders tab revealed an admission date of 06/17/25 with diagnoses including diabetes, kidney failure and colostomy (a surgical procedure which creates an opening from the large intestine through the abdominal wall). P8 was discharged from Home Health on 08/15/25. The physician’s orders included a skilled nurse to visit one time a week for nine weeks. Review of P9's EMR revealed no discharge summary. During an interview on 08/22/25 at 10:35 AM, the acting Executive Director confirmed the HHA failed to document a discharge summary and send the summary to the attending physician for P8 and P9.

An onsite Emergency Preparedness Survey was conducted at Chesterfield Visiting Nurses from 01/31/2022 - 02/03/2022. The Home Health Agency is in substantial compliance with the Medicare Condition at 42 CFR 418.113 (Establishment of the Emergency Program). The following standard level deficiencies were identified during the survey

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on record reviews and interview, the Home Health Agency(HHA) failed to document when the HHA's Emergency Preparedness Program Plan(EPP) was last reviewed and updated. On 2/2/2022 at 3:30 PM, review of the Home Health Agency’s EPP revealed no data to document the last update and/or revision of the EPP. The finding was verified by Administrator #1 at 3:30 PM on 2/2/2022.

An onsite Recertification survey was conducted at Chesterfield Visiting Nurses from 01/31/2022 - 02/03/2022. The Home Health Agency is in substantial compliance with the Medicare Conditions of Participation at 42 CFR PART 484. The following standard level deficiencies were identified during the survey.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on record review and interview, the Skilled Nurse (SN) failed to document patient’s rights and advanced directive information given and explained to patient in one out of seven charts reviewed (Patient #6). Patient #6 On 2/1/2022 at 3:03 PM, review of Patient #6’s chart revealed there was no documentation to show the patient received either information related to patient rights and/or advanced directives from the Home Health Agency. The finding was verified by Administrator #1 and Administrator #2 at 3:49 PM on 2/2/2022.

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 record review and interview, the SN failed to make some outcomes on the Plan Of Care (POC) measurable in two out of two charts reviewed with Aide services (Patient #1 and #6). Patient #1 On 2/1/2022 at 9:13 AM, a review of Patient #1’s chart reveals the POC has outcomes which are not measurable (Promote healthful environment; promote safe personal care and hygiene; maintain clean, safe environment, promote skin integrity; and optimal independence). This finding is verified by Administrator #1 and Administrator #2 at 4:19 PM on 2/2/2021. Patient #6 On 2/1/2022 at 3:03 PM, a review of Patient #6’s chart the POC has outcomes which are not measurable (Promote skin integrity and Promote safe, personal care and hygiene). This finding is verified by Administrator #1 and Administrator #2 at 3:49 PM on 2/2/2022.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to include psychosocial data on the individualized Plan of Care (POC) for seven out of seven patient charts reviewed (Patient #1, #2, #3, #4, #5, #6, and #7). Patient #4 On 1/31/2022 at 1:45 PM, a review of Patient #4’s chart reveals the patient’s POC does not contain psychosocial data. This finding is verified by Administrator #1 and Administrator #2 at 4:37 PM on 2/2/2022. Patient #1 On 2/1/2022 at 9:13 AM, a review of Patient #1’s chart reveals the patient’s POC does not contain psychosocial data. This finding is verified by Administrator #1 and Administrator #2 at 4:19 AM on 2/2/2022. Patient #5 On 2/1/2022 at 2:36 PM, a review of Patient #5’s chart reveals the patient’s POC does not contain psychosocial data. This finding is verified by Administrator #1 and Administrator #2 at 4:57 PM on 2/2/2022. Patient #7 On 2/1/2022 at 3:32 PM, a review of Patient #7’s chart reveals the patient’s POC does not contain psychosocial data. This finding is verified by Administrator #1 and Administrator #2 at 3:17 PM on 2/2/2022. Patient #2 On 2/2/2022 at 9:16 AM, a review of Patient #2’s chart reveals the patient’s POC does not contain psychosocial data. This finding is verified by Administrator #1 and Administrator #2 at 4:47 AM on 2/2/2022. Patient #3 On 2/2/2022 at 2:39 PM, a review of Patient #3’s chart reveals the patient’s POC does not contain psychosocial data. This finding is verified by Administrator #1 and Administrator #2 at 4:50 PM on 2/2/2022. Patient #6 On 2/2/2022 at 3:03 PM, a review of Patient #5’s chart reveals the patient’s POC does not contain psychosocial data. This finding is verified by Administrator #1 and Administrator #2 at 3:49 PM on 2/2/2022.

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 Skilled Nurse (SN) failed to follow the Plan Of Care (POC) orders in four out seven patient charts reviewed (Patient #1, #4, #5, and #7). Patient #4 On 1/31/2022 at 1:45 PM, a review of Patient #4’s chart reveals the patient is admitted with Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease on 12/10/2021. The POC states, “SN to weigh patient every visit. Report weight gain greater than two pounds in one day or greater than five pounds in one week to physician. Instruct patient to weigh daily and report abnormal” weights. The POC shows a diet order of “1800 American Diabetes Association (ADA) diet, Low Sodium, Heart Healthy, Renal Diet, Low Fat”. The SN made visits on 12/10/2021, 12/13/2021, 12/17/2021, 12/20/2021, 12/22/2021, 12/28/2021, and 1/4/2022. The SN documents a weight of 205 pounds on 12/10/2021. The rest of the visits above there is no documentation of the patient’s weight by the SN. This finding is verified by Administrator #1 and Administrator #2 at 4:37 PM on 2/2/2022. Patient #1 On 2/1/2022 at 9:13 AM, a review of Patient #1’s chart reveals the patient is admitted on 7/16/2021. The benefit period reviewed is dated 11/13/2021 to 1/11/2022. The patient is admitted with Critical Illness Myopathy and Type 2 Diabetes Mellitus without complications. The diet ordered is 1800 American Diabetes Association (ADA diet), Low Sodium, Heart Healthy, Low Fat. The POC states, “Assess blood sugar monitoring and results. Notify physician of random blood sugar above 250 milligrams per deciliter (mg/dL, or any fingerstick blood sugar below 60 mg/dL, or fasting blood sugar above 150 mg/dL. SN may accept patient fingerstick blood sugar results.” The SN made visits on 11/19/2021, 11/23/2021, 11/30/2021, 12/7/2021, 12/14/2021, 12/20/2021, 12/28/2021, 1/4/2022, and 1/10/2022. The only visit where a blood sugar is documented is the visit dated 11/19/2021. On the visit dated 12/28/2021 and 1/4/2021, the SN documents glucose within normal limits. These findings are verified by Administrator #1 and Administrator #2 at 4:19 PM on 2/2/2022. Patient #5 On 2/1/2022 at 2:36 PM, a review of Patient #5’s chart reveals the patient was admitted on 11/24/2021 with a diagnosis of “Encounter for Change or Removal of Surgical Dressing, Type 2 Diabetes Mellitus with other specified complication, Type 2 Diabetes with Diabetic Peripheral Angiopathy with Gangrene, Type 2 Diabetes Mellitus with Hyperglycemia, and Type 2 Diabetes with Diabetic Neuropathy, Unspecified.” The POC states, “Instruct on diabetic foot care.” Notify Physician of “Random blood sugar above 250 mg/dl or any Fingerstick below 60 mg/dl or Fasting blood sugar above 150. SN may accept patient’s fingerstick blood sugar results.” The POC shows orders for wound care for a “Left distal foot amputation wound.” Also, SN to measure wound at least weekly, teach regarding signs and symptoms of complications of diabetes, assess for signs and symptoms of hypoglycemia and hyperglycemia, teach/reinforce general principles of prescribed diet.” The SN made visits dated 11/24/2021, 11/26/2021, 11/29/2021, 12/1/2021, 12/3/2021, 12/6/2021, 12/8/2021, 12/10/2021, 12/14/2021, 12/15/2021, 12/17/2021, 12/20/2021, 12/22/2021, 12/24/2021, 12/27/2021, 12/28/2021, 12/31/2021, 1/3/2022, 1/5/2022, 1/7/2022, 1/10/2022, 1/12/2022, 1/14/20 22, 1/17/2022, 1/19/2022, and 1/21/2022. The chart reveals the SN did not document wound measurements for the weeks of 11/28/2021 (visits 11/29/2021, 12/1/2021, and 12/3/2021) and 12/19/2021 (visits 12/20/2021, 12/22/2021, and 12/24/2021). The only visits the SN documented blood glucose levels are visits dated 11/26/2021, 12/3/2021, 12/8/2021, 12/17/2021, and 12/222021. This finding is verified by Administrator #1 and Administrator #2 at 4:57 PM on 2/2/2022. Administrator #1 states, “Wound measurements are to be documented weekly per policy.” Patient #7 On 2/1/2022 at 3:32 PM, a review of Patient #7’s chart reveals the POC orders state, “Notify physician if Systolic Blood Pressure is above 160 mm/Hg.” On 12/27/2021, a visit by the Skilled Nurse (SN) documents a blood pressure of “168/72 millimeter of mercury (mmHg).” The visit note does not contain documentation of the SN’s notification to the physician of the blood pressure outside of prescribed limits. The POC orders state, notify physician of “random blood sugar above 250 mg/dL, or any fingerstick blood sugar below 60 mg/dL, or fasting blood sugar above 150 mg/dL. SN may accept patient’s fingerstick blood sugar results. SN to weigh patient every visit. Report weight gain greater than two pounds in one day or greater than five pounds in one week to physician.” The patient was admitted on 11/18/2021 with “Hypertensive Heart Disease with Heart Failure and Type 2 Diabetes Mellitus without complications”. The diet ordered is Low Sodium, No Concentrated Sweets, and Low Fat. The POC states to “teach regarding compliance with Congestive Heart Failure treatment regimen and teach regarding diabetes management and disease process, teach regarding proper foot care, teach/reinforce general principles of prescribed diabetic diet, foods allowed/restricted, and diet management, teach/reinforce principles of prescribed low sodium diet, fools allowed/restricted, and diet management.” The SN made visits on 11/18/2021, 11/22/2021, 11/24/2021, 11/29/2021, 12/2/2021, 12/6/2021, 12/13/2021, 12/20/2021, 12/27/2021, and 1/3/2022 (patient discharge). The only visit a blood glucose is documented is 11/29/2021 (159 mg/dL). The patient’s weight is documented on visits dated 11/18/2021 (325 pounds) and 11/24/2021 (325 pounds). On 11/29/2021, 12/2/202, 12/6/2021, and 12/13/2021, the SN documents “no change” for the patient’s weight. On visits dated 11/22/2021, 12/20/2021, and 12/27/2021 no weights are documented. These findings are verified by Administrator #1 and Administrator #2 at 3:17 PM on 2/2/2022.

Review and revision of the plan of care CFR(s): 484.60(c) Standard: Review and revision of the plan of care. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to update the Plan Of Care (POC) in one out of one chart with a benefit period beyond the initial benefit period (Patient #1). Patient #1 On 2/1/2022 at 9:13 AM, a review of Patient #1,s chart reveals the POC was not updated to the patient’s current status. A goal on the POC states “Complete healing of pressure ulcer without complication, target date of 12/15/2021.” The chart documentation does not show the patient in this certification period has a pressure ulcer. This finding is verified by Administrator #1 and Administrator #2 at 4:19 PM on 2/2/2022.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, the SN failed to make Aide assignment tasks specific (frequency of task) in two out two charts reviewed with Aide services (Patient #1 and #6). Patient #1 On 2/1/2022 at 9:13 AM, a review of Patient #1’s chart reveals some of the tasks on the Aide assignments are not specific as to the frequency of the task (Ambulate patient using assistive device as needed; assist with transfers as needed; shampoo as needed; and shave, safety razor as needed). This finding is verified by Administrator #1 and Administrator #2 at 4:19 PM on 2/2/2021. Patient #6 On 2/1/2022 at 3:03 PM, a review of Patient #6’s chart reveals some of the tasks on the Aide assignments are not specific as to the frequency of the task (Assist with transfers and ambulation as needed and assist to bedside toilet or toilet as needed).This finding is verified by Administrator #1 and Administrator #2 at 3:49 PM on 2/2/2022.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(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 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 §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on record review and interview, the Skilled Nurse (SN) failed to document supervisory visits for the Aide one out of two charts reviewed with Aide services (Patient #1). Patient #1 On 2/1/2022 at 9:13 AM, a review of Patient #1’s chart reveals the SN made an Aide supervisory visit on 11/19/2021 and the next supervisory visit was made on 12/28/2021 (39 days later). The SN visits are dated 11/19/2021, 11/23/2021, 11/30/2021, 12/7/2021, 12/14/2021, 12/20/2021, and 11/28/2021.This finding is verified by Administrator #1 and Administrator #2 at 4:19 PM on 2/2/2022.