Every finding on record at Douglas County Visiting Nurses Association Inc

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification Survey (iQIES1D160A-H1) conducted at the above-named Home Health Agency (HHA) from 08/05/25 to 08/07/25 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.22.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Recertification and Complaint survey (iQIES 1D160A-H1) conducted at the above-named Home Health Agency (HHA) from 08/05/25 to 08/07/25 resulted in a finding of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard level deficiencies cited.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to conduct a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy for 2 (Patient 1 & 6) of 17 sample patients reviewed. This failure to provide patients with an accurate and up-to-date medication list has the potential to contribute to medication errors for all patients receiving home health services. Findings Include: Review of an agency policy titled, "Medication Reconciliation/Drug Regimen Review" dated as reviewed/revised 02/2025, revealed under the "Ongoing" section that staff were to update the medication profile with new, changed or discontinued medications. Patient 1 Review of P1's current Plan of Care (POC) with a Start of Care (SOC) date of 07/29/25, lacked evidence of medication Zinc Oxide 11% topical being ordered or listed on the patient's medication profile. During a visit to P1's residence on 08/05/25 at 3:00 PM, review of the medication profile lacked evidence of Zinc Oxide topical listed for use. The Registered Nurse (RN) provided wound care per orders effective 08/04/25 and discussed the Zinc Oxide use with the family who stated that they had been using it. Patient 6 Review of P6's current Plan of Care (POC) with a Start of Care (SOC) date of 07/24/25, lacked evidence of medication Biofreeze topical gel being ordered or listed on the patient's medication profile. During a visit to P6's home on 08/06/25 at 11:00 AM, patient explained that she had a fall on 07/27/25 and went to urgent care. She stated that she was still sore and bruised but was taking Tylenol (which is currently ordered and on the medication profile) and using Biofreeze as instructed by the urgent care clinician. There was no Biofreeze listed on the patient's current medication list in the home. The Physical Therapy Assistant (PTA) making the visit stated, "but it's over the counter." Review of the visit schedule revealed that there was a home visit made to see the patient on 08/04/25 which was after the patient started the medication however, it had not been added to the POC or medication profile. During an interview on 08/07/25 at 4:00 PM, Staff D, Therapy Director (who observed all home visits with the surveyor) confirmed the finding of the above medications not being included on the patient's medication profile or an updated Medication Reconciliation or Drug Regimen Review being performed.

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, observation, and staff interview, the agency failed to ensure all patients plans of care (POC) included all required elements, such as medications, treatments, and safety measures for 4 (Patients 1, 6, 7, 9) of 17 sample patients. This failure placed all patients at risk for unmet care needs, and adverse outcomes. Findings Include: Patient 1 Review of Patient 1's clinical record with a Start of Care date of 07/29/25 and a Primary Diagnosis of Pressure Ulcer to right buttock, indicated wound care was to be provided. During home observation visit on 08/05/25 at 3:00 PM with the Skilled Nurse, she indicated that the family was using Zinc Oxide 11% topical gel on the patient's bottom. However, review of the medications listed on the POC did not note Zinc Oxide being used. Patient 6 Review of Patient 6's clinical record with a Start of Care date of 07/24/25 and a Primary Diagnosis of Venous Insufficiency, indicated the patient was to have Physical Therapy in the home. During home observation visit on 08/06/25 at 11:00 AM with the Physical Therapy Assistant (PTA), the patient explained to the surveyor that she had a fall on 07/27/25 and was taking Tylenol for pain as ordered and using Biofreeze, which was ordered by the urgent care clinician. However, review of the medications listed on the POC did not include Biofreeze which was started on 07/27/25. Record review revealed therapy had made a home visit on 08/04/25 and did not document the Biofreeze on the POC. Patient 7 Review of Patient 7's clinical record with a Start of Care date of 07/15/25 and a Primary Diagnosis of Dislocation of Internal Right Hip Prosthesis, indicated the patient was to receive Therapy and aide services. The POC listed Aspirin 81 mg one tab orally one time a day. The Aspirin was also denoted as a "HIGH RISK MEDICATION". However, there were no bleeding precautions listed under the safety measures of the POC. Patient 9 Review of Patient 9's clinical record with a Start of Care date of 07/08/25 and a Primary Diagnosis of Encounter for Attention to Cystostomy, indicated the patient was to receive monthly catheter changes. The POC listed Aspirin 81 mg one tab orally one time a day. The Aspirin was also denoted as a 'HIGH RISK MEDICATION". However, there were no bleeding precautions listed under the safety measures of the POC. During an interview conducted on 08/07/25 at 10:00 AM, Staff A confirmed the above findings of all the medications, treatments, and safety measures for the patients not being included in their current Plans of Care.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on home visit observation, and agency policy review, it was determined the Home Health Agency (HHA) failed to follow acceptable standards of practice, including the use of standard precautions to prevent infections and communicable diseases for 3 (Patients 2,3,4) of 7 home observation visit. This failure of not adhering to standard precaution when providing patient care had the potential to place all patients on service at a high risk of infection. Finding Include: Review of Agency Policy 9-013 titled, "VNA Healthcare Bag Technique" indicated when in the home the clinician should identify a clean and safe area for the healthcare bag. The policy also states, "never set the healthcare bag on the floor", spread a barrier before setting the bag down, remove any items needed for patient care, close the bag before performing patient care, wash hands again if you need to re-enter the bag for additional supplies during patient care. The policy explained that assessment equipment is to be cleaned with approved wipes or spray and placed on the designated clean area on the barrier near the bag, then wash hands and repack and close the healthcare bag. Patient 2 During home observation visit on 08/06/25 at 9:00 AM, the clinician left the healthcare bag open while conducting the visit. The clinician went back into the bag to retrieve supplies without sanitizing hands prior, after touching the patient. The clinician removed one glove and left one glove on to clean reusable equipment and failed to place the equipment on a clean barrier to dry but, immediately returned it to the healthcare bag. Patient 3 During home observation visit on 08/06/25 at 9:30 AM, the clinician place the barrier and the healthcare bag on the floor and left it open, she also went back into the bag to retrieve the blood pressure cuff without sanitizing her hands, after having touch the patient and taken his temperature. The clinician cleaned the reusable equipment and immediately returned it to the healthcare bag. Patient 4 During home observation visit on 08/06/25 at 10:00 AM, the clinician placed her backpack on the patient's "coffee table" without the use of a barrier. The clinician sat on the floor and crawled around on her knees to perform wound care to the patient's foot. During an interview, conducted on 08/07/25 at 9:00 AM with Agency Staff A she confirmed the above findings of agency staff not adhering to standard precaution when providing in home patient care as outlined in agency policy.

12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This STANDARD is not met as evidenced by: Based on review of agency documentation of home health aide 12 hours of in-service training provided, HR file review, and staff interview, the home health agency failed to provide the required 12 hours of training for 1 (staff F) of 1 CNA (Certified Nursing Assistant) record reviewed. This failure had the potential for patients to not receive the appropriate services by a qualified and trained aide and place the patients at risk of harm or unmet needs. Findings Include: Review of agency Relias Training Certificates for Staff F, reveals a total number of hours provided during the calendar year of 2024 to be 5.75 hours. Review of agency Job Description Summary for "Certified Nurses Aide/Certified Home Health Aide" provided to Staff F, indicated that as part of the aide's duties they are to maintain skills through attendance at annual skills fair or other continuing education opportunities, and to complete required in-service hours in a timely manner. During an interview 08/06/25 at 3:00 PM with Staff C, Agency Director of Finance and HR, she confirmed the above findings of the CNA (Certified Nursing Assistant) not having the full 12 hours of in-service for 2024. She also stated that the CNA had been out for a couple of months during 2024.

On behalf of the Centers for Medicare & Medicaid Services (CMS), an unannounced on-site Complaint survey (6104B-H1, 100443) was conducted at the above-named Home Health Agency (HHA) from 09/20/23 through 09/21/23 resulted in findings of substantial compliance respective to applicable Condition of Participation (CoP) under 42 CFR 484, Subpart A through C with the following standard-level deficiencies cited.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on review of agency administrative documents and staff interview the home health agency failed to have a qualified, pre-designated person appointed by the governing body to act as the administrator when the administrator is not available. This deficient practice has the potential to affect the safety of all patients receiving care from this home health agency. Finding Include: Review of a document titled, "VNA Board Meeting Minutes" dated November 28, 2012, indicated that Staff A had been appointed Administrator for the agency, however, there was no indication of anyone being appointed as an alternate Administrator in Staff A's absence. During an interview on 09/20/23 at 4:00 PM, Staff C confirmed that the agency's Governing Body had not appointed anyone as the designated Administrator in writing. She also stated that Staff A, Administrator just assigns someone when she is going to be away from the office.

Clinical manager CFR(s): 484.105(c) Standard: Clinical manager. One or more qualified individuals must provide oversight of all patient care services and personnel. Oversight must include the following-- This STANDARD is not met as evidenced by: Based on observation, agency administrative document review, and staff interview the home health agency failed to ensure only qualified professional staff functioned in the role of Clinical Manager who makes patient and personnel assignments and coordinates patient care and referrals. The home health agency's failure to ensure qualified professionals in the role of Clinical Manager places all patients currently on service at risk for unmet needs and or adverse outcome due to the lack oversite by a qualified licensed professional. Findings Include: Review of a document titled, “Job Description Summary” for job title of Home Health Team Manager, revealed that the educational and licensure requirements for the job were that of a Registered Nurse (RN) with a minimum of Bachelor of Science in Nursing Degree. Review of the same above titled document signed on 08/22/22 by Staff D indicated the staff member to be a Licensed Practical Nurse (LPN) and not an RN. Review of the Home Health Agency’s Organizational Chart indicated that Staff D, LPN was listed as “Home Health Team Manager. The duties and responsibilities listed on the “Job Description Summary” indicated the Home Health Team Manager was to perform scheduling of staff member, review OASIS [Outcome and Assessment Information Set - data set that shows social, functional and clinical status of the patient at specific times] and coding, perform audits, conduct staff meetings/case conferences, coordinate communication between staff, patients and physicians, as well as to recruit, interview, hire, orient and supervise staff. During an interview on 09/20/23 at 2:30 PM, Staff D, LPN, when asked what her role was in the agency, she stated, “oversee patient care, review charts, check for documentation, run team meetings, review OASIS, 485 [patient plan of care and orders signed by the patient's primary care provider], oversee intake, referrals, and schedule visits to staff members”. Surveyor also asked Staff D if she had been in the role of Home Health Team Manager and signed a job description for the same job title. She stated that yes, she had until yesterday. During an interview on 09/20/23 at 3:55 PM, Staff C, Director of Operational Excellence, confirmed that Staff D, LPN had been in the role of Team Manager and was overseeing staff.

Clinical Manager CFR(s): 484.115(c) Standard: Clinical manager. A person who is a licensed physician, physical therapist, speech-language pathologist, occupational therapist, audiologist, social worker, or a registered nurse. This STANDARD is not met as evidenced by: Based on observation, agency administrative document review, and staff interview the home health agency failed to ensure only qualified professional staff functioned in the role of Clinical Manager. The home health agency's failure to ensure qualified professionals in the role of Clinical Manager placed all patients currently on service at risk for unmet needs and or adverse outcome due to the lack oversite by a qualified licensed professional. Findings Include: Review of a document titled, “Job Description Summary” for job title of Home Health Team Manager, revealed that the educational and licensure requirements for the job were that of a Registered Nurse (RN) with a minimum of Bachelor of Science in Nursing Degree. Review of the same above titled document signed on 08/22/22 by Staff D indicated the staff member to be a Licensed Practical Nurse (LPN) and not an RN. Review of the Home Health Agency’s Organizational Chart indicated that Staff D, LPN was listed as “Home Health Team Manager. The duties and responsibilities listed on the “Job Description Summary” indicated the Home Health Team Manager was to perform scheduling of staff member, review OASIS and coding, perform audits, conduct staff meetings/case conferences, coordinate communication between staff, patients and physicians, as well as to recruit, interview, hire, orient and supervise staff. During an interview on 09/20/23 at 2:30 PM, Staff D, LPN, when asked what her role was in the agency, she stated, “oversee patient care, review charts, check for documentation, run team meetings, review OASIS, 485, oversee intake, referrals, and schedule visits to staff members”. Surveyor also asked Staff D if she had been in the role of Home Health Team Manager and signed a job description for the same job title. She stated that yes, she had until yesterday. During an interview on 09/20/23 at 3:55 PM, with Staff C, Director of Operational Excellence, confirmed that Staff D, LPN had been in the role of Team Manager and was overseeing staff.