Every finding on record at Lighthouse Home Health Care LLC

Unannounced visits were concluded at Lighthouse Home Health Care on 07/18/2024 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 on 07/18/2024 at Lighthouse Home Health Care in Stratford for the purpose of a recertification survey. Standard-level deficiencies were identified.

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 clinical record reviews, review of an agency policies and interview with agency staff, for one of three patients (Patient #1) in the survey sample who required weight monitoring, the agency nurses failed to follow physician’s orders. The findings include: Patient #1 had a start of care date of 6/24/2024 with the diagnoses to include hypertension, atrial fibrillation, coronary artery disease, and malignant neoplasm of prostate. The physician orders for the certification period of 6/24/24 to 8/22/24 included skilled nursing services two times per week for one week, to assess fluid retention, cardiovascular status, and for the monitoring of patient weights at every nursing visit, and report a weight gain of five (5) pounds in a week, and/or a weight gain of two (2) pounds or greater in twenty-four hours. Interview and review of Patient #1’s clinical record with the Administrator on 7/18/ 24 at 10am, identified the agency nurses failed to weigh the Patient on five of the six visits, on 6/24, 6/27, 7/2, 7/5, and 7/10/24. The only weight was obtained on 7/16/24, 144 pounds. Review of the Assessment policy identified the purpose was to provide thorough , ongoing, patient care based on accurate assessment, which gives basis for interventions and realistic expected outcomes.

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 clinical record reviews and interview with the agency personnel, for one of ten patients (Patient #6) in the survey sample, the agency nurses failed to ensure initial, comprehensive and ongoing assessments of a surgical incision were completed in accordance with the agency's policies. The findings include: a. Patient #6 had a start of care date of 06/27/2024 with diagnoses that included a right hip fracture, right hip repair on 05/30/2024, type II diabetes, chronic heart failure, and a history of falls. The physician’s orders for the certification period of 06/27/2024 to 08/25/2024 included nursing services three times per week for eight weeks for nursing assessments, and physical therapy twice per week for two weeks. Review of Patient #6’s start of care nursing summary and care plan dated 06/27/2024, failed to identify the Patient had a surgical incision. Review of Patient #6’s nursing note dated 07/01/2024, failed to identify the Patient had a surgical incision. Review of Patient #6’s nursing note dated 07/03/2024, identified Licensed Practical Nurse (LPN) #1 observed Patient #6 had a surgical incision to the right hip which was approximated with a total of thirty-five staples. Review of a communication note by the Administrator dated 07/03/2024, identified LPN #1 reported observing a surgical incision to Patient #6's right hip which was approximated with staples during the 07/03/2024 visit. The Administrator further indicated a review of the start of care nursing summary and care plan dated 06/27/2024, failed to identify the Patient's right hip was assessed and a surgical incision was present. i. Interview and review of Patient #6’s clinical record with the Administrator on 07/18/2024 at 11:00 AM, identified the agency’s nurses failed to conducted initial, comprehensive and ongoing assessments of Patient #6’s right hip surgical incision in accordance with the agency’s Initial, Comprehensive and Ongoing Assessments and Wound Care policies. Review of the agency’s Initial and Comprehensive Assessment policy identified the assessment would be patient specific and comprehensive to include the patient’s needs. The Assessment policy further identified the purpose was to provide thorough, ongoing, patient care based on accurate assessments, which gives basis for interventions and realistic expected outcomes. Review of the agency’s Ongoing Assessments policy identified during each home visit the appropriate clinician would re-evaluate the patient according to the problems identified during the initial visit and thereafter. Review of the agency’s Wound care policy identified the purpose was to provide comprehensive treatment for simple and complex wounds to achieve wound healing providing the patient’s needs. The primary care nurse would be responsible for assessing the wound/incision, obtain and carry out wound care orders

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record reviews, review of agency policies and interviews with agency personnel, for one of three patients (Patient #1) in the survey sample who required weight monitoring and one of one patient (Patient #6) in the survey sample who required surgical incision monitoring, the agency nurse failed to provide the necessary assessments. The findings included: Patient #1 had a start of care date of 6/24/2024 with the diagnoses to include hypertension, atrial fibrillation, coronary artery disease, and malignant neoplasm of prostate. The physician orders for the certification period of 6/24/24 to 8/22/24 included nursing services two times per week for one week to assess fluid retention, cardiovascular status, and weigh patient every visit and report a weight gain of five pounds in a week or greater than two pounds in twenty-four hours. Interview and review of Patient #1’s clinical record with the Administrator on 7/18/ 24 at 10am, identified the agency nurses failed to weigh the Patient on five of the six visits, on 6/24, 6/27, 7/2, 7/5, and 7/10/24. The only weight was obtained on 7/16/24, 144 pounds. Review of the Assessment policy identified the purpose was to provide thorough , ongoing, patient care based on accurate assessment, which gives basis for interventions and realistic expected outcomes. b. Patient #6 had a start of care date of 06/27/2024 with diagnoses that included a right hip fracture, right hip repair on 05/30/2024, type II diabetes, chronic heart failure, and a history of falls. The physician’s orders for the certification period of 06/27/2024 to 08/25/2024 included nursing services three times per week for eight weeks for nursing assessments, and physical therapy twice per week for two weeks. Review of Patient #6’s start of care nursing summary and care plan dated 06/27/2024, failed to identify the Patient had a surgical incision. Review of Patient #6’s nursing note dated 07/01/2024, failed to identify the Patient had a surgical incision. Review of Patient #6’s nursing note dated 07/03/2024, identified Licensed Practical Nurse (LPN) #1 observed Patient #6 had a surgical incision to the right hip which was approximated with a total of thirty-five staples. Review of a communication note by the Administrator dated 07/03/2024, identified LPN #1 reported observing a surgical incision to Patient #6's right hip which was approximated with staples during the 07/03/2024 visit. The Administrator further indicated a review of the start of care nursing summary dated 06/27/2024, failed to identify the Patient's right hip was assessed. ii. Interview and review of Patient #6’s clinical record with the Administrator on 07/18/2024 at 11:00 AM, identified the agency’s nurses failed to conducted an initial and comprehensive assessment of Patient #6’s right hip surgical incision in accordance with the agency’s policy. Review of the agency’s Initial and Comprehensive Assessment policy identified the assessment would be patient specific and comprehensive to include the patient’s needs. Review of the agency’s Ongoing Assessments policy identified during each home visit the appropriate clinician would re-evaluate the patient according to the problems identified during the initial visit and thereafter.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on review of agency documentation and interview with the agency personnel, the agency failed to ensure the Administrator was available onsite during operating hours on a consistent basis. The findings include: During the entrance conference on 07/16/2024 at 09:20 AM with the Administrator, she identified functioning as the full-time (forty-hours per week) Administrator for the home health agency. Review of the Administrator and agency nurses’ schedules for the month of April, May, June, and July of 2024, identified the Administrator made six nursing visits in April, five nursing visits in May, fifteen nursing visits in June and ten nursing visits in July of 2024. Interview with the Administrator on 07/18/2024 at 11:30 AM, identified she was functioning as the full time (forty-hours per week) Administrator for the home health agency and was responsible for all day-to-day operations of the provider and supervision of the provider staff, interpreting and executing agency policies, and maintaining the agency’s compliance with licensure regulations and standards. In addition to the role of Administrator, she was responsible for conducting nursing visits to patients in the community. The agency failed to ensure the Administrator was available onsite during operating hours on a consistent basis and available to the home health agency staff, patients and representatives and failed to ensure the Administrator was available to consistently supervised patient care services throughout patient episodes to ensure high quality care.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on review of clinical records, review of an agency policy and interview with agency personnel, for one (Patient #7) of ten patients in the survey sample who received nursing services, the agency’s nurse failed to ensure clinical records were complete and incorporated into the patient’s record. The findings include: a. Patient #7 had a start of care date of 06/14/2024 with diagnoses that included cardiac surgery, hypertensive heart disease with heart failure, type II diabetes, high cholesterol, and falls. The physician’s orders for the certification period of 06/14/2024 to 08/12/2024 included nursing services twice per week for four weeks for nursing assessments, occupational therapy services once per week for four weeks and physical therapy services twice per week for four weeks. i. Interview and review of Patient #7’s clinical record with the Administrator on 07/17/2024 at 1:30 PM, identified nursing notes dated 06/24/2024, 06/27/2024, 07/01/2024, 07/05/2024 and 07/08/2024, were incomplete. The Administrator further identified the agency’s Registered Nurse (RN) #1 failed to ensure nursing notes were completed on the date services were rendered and incorporated into Patient #7’s clinical record within twenty-four to forty-eight hours after the visit. Review of the agency’s Ongoing Assessments policy identified visit notes were to be written within 24-48 hours after the visit and incorporated into the patient’s clinical record.

Unannounced visits were concluded at Lighthouse Home Health Care on 7/26/2021 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 were concluded at Lighthouse Home Health Agency on 7/26/21 for the purpose of recertification. Standard-level defciencies were identified.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and interview with the agency personnel, for one of thirteen patients (Patient#9) in a survey sample, the agency nurse failed to follow the physician orders. The findings include: Patient #9 had a resumption of care date of 7/16/2021 and diagnoses that included a new blister to the right heel, peripheral vascular disease and venous stasis ulcers to bilateral lower extremities. The interim physician orders dated 7/16/2021 included nursing services twice a week for wound care to heel and bilateral lower extremities, and assessments. The wound care orders to the right heel included Xeroform dressing followed by Kerlix and ace wraps twice a week. Observation during a home visit on 7/23/2021 with RN #3 identified that RN #3 removed old dressing from the right heel (the dressing had some discharge on it), discarded old dressing, sanitized hands, changed gloves, then applied white round pad ( that was not Xeroform dressing) ,wrapped kerlix around the heel and ace wraps around the right heel, and continued with the visit. Interview and review of the home visit observation on 7/23/2021 with the Administrator on 7/26/2021 at 1:50 PM identified that RN#3 completed the wound care but failed to apply Xeroform as directed by physician orders to the right heel.

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 clinical record review and interview with the agency personnel, for one of thirteen patients (Patient #4) in the survey sample, the agency Registered Nurses (RN) failed to ensure monthly supervision of the Licensed Practical Nurses (LPN) and/or for three of four patients ( Patient #4, #6 & #9 ) who required wound care, the agency nurses failed to ensure weekly wound measurements were completed in accordance with the agency policy. The findings include: 1. Patient #4 had a start of care date of 5/27/21 and diagnoses that included stage IV pressure ulcer of the sacrum, peripheral vascular disease, bullous pemphigoid and type II diabetes mellitus. The physician's orders dated 5/27/21 included nursing services 3 times a week for assessments and wound care to the sacrum and right hip blisters. a. Interview and review of the nursing notes from 6/04/21 to 7/23/21 (7 weeks) with the Administrator on 7/26/21 at 10:00 AM identified that 12 out of 19 visits were completed by LPN's but failed to identify monthly supervision of the LPN's documented by the RN in the clinical record. Review of agency policy for duties of the LPN, directed in part that LPN ' s will function under the supervision of the RN. Documentation will be reviewed by the RN and case conferencing will occur upon orientation of the patient care plan and at least every month or more often as needed. b. Interview and review of the nursing notes from 5/27/21 to 7/23/21 with the Administrator on 7/26/21 at 10:00 AM failed to identify weekly wound measurements for the weeks of 6/13/21 to 6/19/21, 6/27/21 to 7/03/21 and 7/04/21 to 7/09/21. 2. Patient #6 had a start of care date of 4/02/2021 and diagnoses that included stage IV pressure ulcer of sacral region, type II diabetes mellitus, peripheral vascular disease and heart failure. The physician's orders dated 06/13/2021 included nursing services three times a week for wound care to the patient's sacral region. Interview and review of the nursing notes from 6/27/2021 to 07/17/2021 with the Administrator on 7/26/2021 at 1:30 PM failed to identify wound measurements for the week of 6/27/2021 to 7/03/2021 and 7/11/2021 to 7/17/2021 and failed to identify weekly wound measurements in accordance with the agency policy. 3. Patient#9 had a resumption of care date of 7/16/2021 and diagnoses that included a new blister to the right heel, peripheral vascular disease and venous stasis ulcers to bilateral lower extremities. The interim physician orders dated 7/16/2021 included nursing services twice a week for assessments, wound care to heel and bilateral lower extremities. The wound care orders to right heel included Xeroform dressing followed by kerlix and ace wraps twice a week. a. Interview and review of the nursing note dated 7/20/21 with the Administrator (RN#4) on 7/27/2021 identified that she completed the visit on 7/20/2021 and documented that the blister broke but failed to measure the area. b. Observation during a home visit on 7/23/2021 with RN#3 identified that RN#3 removed old dressing from the right heel (the dressing had some discharge on it) discarded old dressing, sanitized hands, changed gloves, then applied white round pad ( that was not Xeroform dressing), wrapped kerlix and ace wraps around the right heel, and continued with the visit. Interview and review of the home visit observation on 7/23/2021 with the Administrator on 7/26/2021 at 1:50 PM identified that RN#3 completed the wound care to the right heel but failed to apply Xeroform as directed by physician orders and to complete weekly wound measurements. Review of the agency policy for Wound Care directed the measurement of wounds weekly.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on review of the clinical record and interview with agency personnel, one of one patient (Patient #3) who required assessments of the dressing over the Peripherally Inserted Central Catheter (PICC) insertion site and/or for one of one patient (Patient #8) with an arterio-venous fistula (AVF) for hemodialysis treatment, the agency Registered Nurse/RN failed to provide the necessary assessments. The findings include: Patient# 3 had a start of care date of 6/18/2021 and diagnoses that included osteomyelitis with Methicillin Resistant Staphylococcus Infection (MRSA) of the left ankle and foot, hypertension and chronic obstructive pulmonary disease. The physician orders for the certification period of 6/18/2021 through 8/16/2021 included nursing services three times a week for five weeks, then two times a week for two weeks for wound care, patient teaching and assessments. a. The start of care nursing assessment dated 6/18/2021 identified the presence of a Peripherally Inserted Central Catheter (PICC) . The Memorandum Of Understanding (MOU) developed between the Home Health Agency and the Infusion Company on 6/24/2021 identified the shared responsibilities of both the home health agency and the Infusion Company in patient assessment, education on intravenous (IV) matters, and communicating changes in the patient condition and medical orders. Interview and review of RN#2 notes from 6/18/21 through 7/20/21 with the Administrator on 7/26/2021 at 1:35 PM failed to identify documented nursing assessments of the condition of the dressing over the PICC line insertion site. b. Interview with the Administrator on 7/26/2021 at 1:35 pm identified that the agency failed to develop a policy for nursing personnel to follow in an instance where a patient has a PICC line. Patient #8 had a start of care date of 1/23/21 and diagnoses that included fracture of the right femur and ribs, diabetes mellitus type II, end-stage renal disease receiving hemodialysis treatment and post-operative arterio-venous fistula (AVF) of the left arm. The physician's orders for the certification period of 1/23/21 to 3/23/21 included nursing services for vital signs monitoring and assessments. a. Interview and review of RN #2 ' s nursing visit notes dated 2/09/21, 2/25/21, 3/11/21 and 3/16/21 with the Administrator on 7/26/21 at 12:00 PM failed to identify nursing assessments of the patient's left AV fistula; b. Interview and review of the agency documentation with the Administrator on 7/26/21 at 12 PM failed to identify agency policies and procedures on the assessment of arterio-venous fistulas and/or other implanted hemodialysis access.

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 review of the clinical record and interview with agency personnel, for one of one patient (Patient #10) with a diagnosis of congestive heart failure and/or the need for medication management, the agency nurse failed to communicate with the physician in order to coordinate the patient care. The findings include: Patient #10 had a start of care date of 4/06/21 and diagnoses that included acute and chronic respiratory failure, chronic obstructive pulmonary disease and congestive heart failure (CHF). The physician's orders for the certification period of 6/05/21 to 8/03/21 included nursing services one time a week to assess respiratory and cardiac status and instruct on oxygen use. a. Interview and review of the nursing visit notes with the Administrator on 7/26/21 at 10:40 AM indicated that RN #1 visited the patient on 6/09/21, 6/12/21 and 6/14/21 and LPN #1 visited the patient on 6/21/21 and 6/30/21 but failed to identify nursing communication with the physician for the frequency for weights, and/or the parameters for reporting weight gain to the physician. b. Interview and review of the nursing visit notes with the Administrator on 7/26/21 at 10:40 AM identified the weekly pre-pouring of the patient ' s medications on 6/09/21, 6/14/21, 6/21/21 and 6/30/21 but failed to identify nursing communication with the physician to obtain the physian order for weekly medication pre-pour due to the patient's non-compliance.

Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This ELEMENT is not met as evidenced by: Based on review of the clinical record and interview with agency personnel, for one of six patients (Patient #8) who received Physical Therapy (PT) skilled services along with physical therapy aide (PTA) aide services, the agency Physical Therapist (PT) failed to supervise the PTA. The findings include: Patient #8 had a start of care date of 1/23/21 and diagnoses that included fracture of the right femur and ribs, diabetes mellitus type II, end-stage renal disease receiving hemodialysis treatment and post-operative arterio-venous fistula (AVF) of the left arm. The physician's orders for the certification period of 1/23/21 to 3/23/21 included nursing services for vital signs monitoring and assessments, physical therapy services 3 times a week for 4 weeks, 2 times a week for 2 weeks and 1 time a week for 2 weeks for gait training and muscle strengthening exercises and home health aide services 2 times a week to assist with personal care, transfers and ambulation. Interview and review of PT #1's visit notes from 1/25/21 to 3/23/21 (an interval of fifty-six days ) with the Administrator on 7/26/21 at 11 AM and failed to identify supervisory visits no less frequently than every thirty days according to agency practice. There was no agency policy to review for supervision of PTA ' s by an RPT.

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 review of the clinical record and interview with agency personnel, for three of six patients (Patient's #1, #8 & #11) who received skilled services along with home health aide services, the agency professionals failed to provide on-site supervisory visits at a minimum every two weeks. The findings include: Patient #8 had a start of care date of 1/23/21 and diagnoses that included fracture of the right femur and ribs, diabetes mellitus type II, end-stage renal disease receiving hemodialysis treatment and post-operative arterio-venous fistula (AVF) of the left arm. The physician's orders for the certification period of 1/23/21 to 3/23/21 included nursing services 2 times a week for 6 weeks and 1 time a week for 2 weeks for vital signs monitoring and assessments, Physical Therapy (PT) services 3 times a week for 4 weeks, 2 times a week for 2 weeks and 1 time a week for 2 weeks for gait training and muscle strengthening exercises and home health aide services 2 times a week to assist with personal care, transfers and ambulation. Interview and review of RN #2 ' s nursing visit notes with the Administrator on 7/26/21 at 11 AM identified an interval of thirty-five days between the two supervisory visits of 2/16/21 and 3/23/21 and failed to identify supervisory visits no less frequently than every two weeks. The agency policy on Home Health Aide Plan of Care directed the clinician to conduct supervisory visits in the home at least every 14 days to ensure the care was provided in accordance with the plan. Patient #1 had a start of care date of 03/24/2021 and diagnoses that included chronic obstructive pulmonary disease, chronic renal failure and high blood pressure. The physician's orders for the recertification period of 05/23/201 to 07/21/2021 included nursing services twice per week for five weeks then once per week for four weeks, physical therapy services once per week for nine weeks and home health aide services twice per week for nine weeks for assistance with personal care. Patient #11 had a start of care date of 03/06/2021 and diagnoses that included Dementia, fracture of the right humerus and repeated falls. The physician's orders for the certification period 03/06/2021 to 05/04/2021 included nursing services twice per week for four weeks then once per week for five weeks, physical therapy services once per week for four weeks, occupational therapy services once per week for two weeks and home health aide services three times per week for nine weeks for assistance with personal care. Interview and review of the nurses' notes with the Administrator on 07/23/2021 at 1:15 PM, identified forty days passed since a home health aide supervisory visit was performed on 06/10/2021 for Patient #1. Furthermore, the Administrator failed to identify a home health aide orientation and supervisory visits no less frequently than every two weeks were performed for Patient #11 from 03/06/2021 through 03/19/2021.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on review of the clinical records and interview with agency personnel, for two of thirteen patients (Patient's #3 & #8 ) in the survey sample, the agency Administrator failed to ensure the development of appropriate policies and procedures for the nursing assessment of Peripherally Inserted Central Catheter (PICC) insertion site and/or arterio-venous Fistula (AVF) and/or for the supervision of PTA services. The findings include: Patient# 3 had a start of care date of 6/18/2021 and diagnoses that included osteomyelitis with Methicillin Resistant Staphylococcus Infection (MRSA) of the left ankle and foot, hypertension and chronic obstructive pulmonary disease. The physician orders for the certification period of 6/18/2021 through 8/16/2021 included nursing services three times a week for five weeks, then two times a week for two weeks for wound care, patient teaching and assessments. a. The start of care nursing assessment dated 6/18/2021 identified the presence of a Peripherally inserted Central Catheter (PICC) . The Memorandum Of Understanding (MOU) developed between the Home Health Agency and the Infusion Company on 6/24/2021 identified the shared responsibilities of both the home health agency and the Infusion Company in patient assessment, education on intravenous (IV) matters, and communicating changes in the patient condition and medical orders. Interview and review of RN#2 notes from 6/18/21 through 7/20/21 with the Administrator on 7/26/2021 at 1:35 pm failed to identify documented nursing assessments of the condition of the dressing over the PICC line insertion site. b. Interview with the Administrator on 7/26/2021 at 1:35 pm identified that the agency failed to develop a policy for nursing personnel to follow in an instance where a patient has a PICC line. Patient #8 had a start of care date of 1/23/21 and diagnoses that included fracture of the right femur and ribs, diabetes mellitus type II, end-stage renal disease receiving hemodialysis treatment and post-operative arterio-venous fistula (AVF) of the left arm. The physician's orders for the certification period of 1/23/21 to 3/23/21 included nursing services for vital signs monitoring and assessments, physical therapy services 3 times a week for 4 weeks, 2 times a week for 2 weeks and 1 time a week for 2 weeks for gait training and muscle strengthening exercises and home health aide services 2 times a week to assist with personal care, transfers and ambulation. a. Interview and review of RN #2 ' s nursing visit notes dated 2/09/21, 2/25/21, 3/11/21 and 3/16/21 with the Administrator on 7/26/21 at 12 PM failed to identify nursing assessments of the patient's left AV fistula; b. Interview and review of the agency documentation with the Administrator on 7/26/21 at 12 PM failed to identify agency policies and procedures on the assessment of arterio-venous fistulas and/or other implanted hemodialysis access. c. Interview and review of PT #1 ' s visit notes from 1/25/21 to 3/23/21 (an interval of fifty-six days ) with the Administrator on 7/26/21 at 11 AM and failed to identify supervisory visits no less frequently than every thirty days according to agency expectations. There was no agency policy to review for supervision of PTA' s by a Physical Therapist.