Every finding on record at Lake Sunapee Region VNA & Hospice

An Emergency Preparedness Survey was conducted on 8/22/24 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR part 484.102 Appendix Z - Rev. HHA Issued: 4/16/21 with no deficiencies cited.

A Health Recertification Survey was conducted from August 20, 2024, through August 21, 2024, pursuant to 42 CFR Part 484, for Home Health Agencies with deficiencies cited.

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, it was determined that the agency failed to submit Outcome and Assessment Information Set (OASIS) assessments timely for 5 out of 2934 records between 8/20/23-8/19/24. Review on 8/20/24 of the Center for Medicare and Medicaid Services (CMS) "HHA [Home Health Agency] Error Summary by Agency" report for 8/20/23-8/19/24 revealed the error "-3330 Records Submitted Late: The submission date is more than 30 days after M0090 on this new record" was noted for 5 records of 2934 assessments submitted. Interview on 8/20/24 at approximately 9:00 a.m. with Staff A (Homecare Manager) confirmed the above findings.

An Emergency Preparedness survey was conducted on 11/3/21 pursuant to 42 CFR 484.102 with no deficiencies cited.

A recertification survey was conducted from 11/2/21 to 11/4/21 pursuant to 42 CFR 484 for Home Health Agencies with deficiencies cited.

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 interview and record review it was determined that the agency failed to follow the written plan of care for the frequency of visits and failed to notify the physician of the missed visits for 6 of 17 patients reviewed for plan of care. (Patient identifiers are #5, #6, #11, #7, #8 and #9). Findings include: Patient #7 Review on 11/3/21 of Patient #7’s "Home Health Certification and Plan of Care" for certification period of 8/20/21-10/18/21 revealed the following orders for discipline treatments: Physical Therapy (PT) 2 visits per week for 4 weeks, then 2 visits per week for 3 weeks, then 1 visit per week for 1 week with a start date of 8/20/21. Review on 11/3/21 of Patient #7’s visit notes revealed that Patient #7 had one missed PT visit on 8/31/21 (which resulted in only one PT visit for that week). Further review revealed the missed PT visit on 8/31/21 was not rescheduled and there was no documentation that the physician was notified of the missed visit. Review on 11/3/21 of Patient #7’s visit notes revealed that Patient #7 had one missed PT visit on 10/7/21 (which resulted in only one PT visit for that week). Further review revealed the missed PT visit on 10/7/21 was not rescheduled and there was no documentation that the physician was notified of the missed visit. Interview on 11/3/21 at approximately 2:20pm with Staff A (Clinical Supervisor) confirmed Patient #7 did not receive the above ordered scheduled PT visits. Staff A confirmed that it was not documented that the physician was notified. Patient #8 Review on 11/3/21 of Patient #8’s "Home Health Certification and Plan of Care" for certification period of 9/28/21-11/26/21 revealed the following orders for discipline treatments: Skilled Nursing (SN) 1 visit per week for 9 weeks with a start date of 9/28/21. Review on 11/3/21 of Patient #8’s visit notes revealed that Patient #8 had one missed SN visit on 10/6/21 (which resulted in zero SN visits for that week). Further review revealed that the missed SN visit on 10/6/21 was not rescheduled and there was no documentation that the physician was notified of this missed visit. Review on 11/3/21 of Patient #8’s visit notes revealed that Patient #8 had one missed SN visit on 10/20/21 (which resulted in zero SN visits for that week). Further review revealed that the missed SN visit on 10/20/21 was not rescheduled and there was no documentation that the physician was notified of this missed visit. Interview on 11/3/21 at approximately 2:20pm with Staff A (Clinical Supervisor) confirmed that Patient #8 did not receive the above ordered SN visits. Staff A confirmed that it was not documented that the physician was notified. Patient #9 Review on 11/3/21 of Patient #9’s "Home Health Certification and Plan of Care" for certification period of 10/13/21-12/11/21 revealed the following orders for discipline treatments: Occupational Therapy (OT) 1 visit per week for 6 weeks. This had a start date of 10/19/21. Review on 11/3/21 of Patient #9’s visit notes revealed that Patient #9 had one missed OT visit on 10/27/21 (which resulted in zero OT visits for that week). Further review revealed that the missed OT visit on 10/27/21 was not rescheduled and there was no documentation that the physician was notified of the missed visit. Interview on 11/3/21 at approximately 2:20pm with Staff A confirmed that Patient #9 did not receive the above ordered OT visits. Staff A confirmed that it was not documented that the physician was notified. Patient #5 Review on 11/3/21 of Patient #5's "Home Health Certification and Plan of Care" with a certification period of 12/1/20 to 01/29/21 revealed the following orders for discipline treatments: Skilled Nursing 1 time a week for 9 weeks with a start date of 12/1/20. Review on 11/3/21 of Patient #5's visit notes revealed that Resident #5 had a Skilled Nursing visits on 12/9/20 and 12/23/20. Further review revealed that on 12/17/20 the clinical note stated cancel skilled nursing visit due to winter storm (which resulted in zero SN visits for that week). There was no documentation the physician was notified of this missed visit or that the visit was rescheduled. Interview on 11/3/21 at 2:43 p.m. with Staff A (Clinical Supervisor) confirmed that there was a missed skilled nursing visit on the above week and that it was not documented that the physician was notified. Patient #6 Review on 11/3/21 of Patient #6's "Home Health Certification and Plan of Care" for certification period of 10/6/21 to 12/4/21 revealed the following order for discipline treatment: Physical therapy 1 time a week for 1 week; then 2 times a week for 4 weeks with a start date of 10/6/21. Review on 11/3/21 of Patient #6's visit notes revealed that Resident #6 had physical therapy visits on 10/6/21 (week 1); 10/12/21 and 10/21/21. There were missed visits documented on the following days (which resulted in Patient #6 only receiving one PT visit for 2 weeks); On 10/14/21 the missed visit note revealed "called patient to schedule PT visit today, left message without receiving call back. Will resume at next scheduled visit." On 10/18/21 the missed visit note revealed "... Patient's daughter reported that patient was suffering from a gluteal furuncle and wouldn't be available for P.T. treatment until end of week." On 10/20/21 the missed visit note revealed "This therapist called patient's daughter... reported that patient had MD [medical doctor] appointments today and wont [sic] be available." There was no documentation that the physician had been notified of the above missed PT visits or had been rescheduled. Interview on 11/3/21 at 2:46 p.m. with Staff A confirmed the above missed PT visits and that there was no documentation the physician had been notified of the missed visits. Patient # 11 Review on 11/3/21 of Patient #11's "Home Health Certification and Plan of Care" for certification period of 9/19/21 to 11/17/21 revealed the following order for discipline treatment: Skilled nursing 1 time a week for 9 weeks with a start date of 9/19/21. Review on 11/3/21 of Patient #11's visit notes revealed that Resident #11 had a SN visit on 10/19/21 and 11/2/21. There was a missed visit on 10/26/21 that read, in part, "PNT [patient] answered declined needing nursing visit, denied concerns..." which resulted in zero SN visit for that week. There was no documentation that the physician was notified of the missed visit. Interview on 11/3/21 at 2:44 p.m. with Staff A confirmed that there was a missed visit for that week and that there was no documentation that the physician had been notified. Review on 11/4/21 of the facility policy titled "Missed Visits" revised April 2017 read, in part, "... Missed visits will be communicated to the clinical supervisor and the patient's physician. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.... 1. If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician-ordered frequency is maintained and would not be considered a missed visit. 2. If a visit is missed and not rescheduled the clinician will: A. Notify the physician and clinical supervisor of the missed visit and reason for missed visit. B. Document in the patient's clinical record...