Every finding on record at Nightingale Home Healthcare of Connecticut, Inc.

Unannounced visits were concluded at Nightingale Home Healthcare of CT., Inc concluding on 7/13/2023 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 regulations at the time of the survey.

Unannounced visits were concluded at Nightingale Home Healthcare of CT, Inc. concluding on 07/13/2023 for the purpose of Recertification. As a result of the survey standard-level deficiencies was identified.

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, review of agency policies and interview with the agency personnel, for one of one patient's (Patient #5) requiring medication management, the agency nurses failed to follow agency policies. The findings include: Patient #5 had a start of care date of 7/10/18 and diagnoses that included schizophrenia, anxiety and chronic obstructive pulmonary disease. The physician's orders for the certification periods of 6/14/23 to 8/12/23 included nursing services weekly for pre-pouring medications and assessments. Physician’s orders directed to pre-pour Clonazepam (a Schedule IV controlled substance) 0.5 mg once a day for anxiety. Interview and review of the Supervisor of Clinical Service/SCS weekly nursing notes from 6/18/23 to 7/09/23 (4 visits) with the Regional RN on 7/13/23 at 10:00 AM identified that Clonazepam was pre-poured weekly but failed to identify a mechanism for counting the number of tablets of Clonazepam found in the bottle, and the remaining balance of the tablets after the nurse accessed the controlled substance and failed to follow agency policies. Review of agency policy for Medication Orders and Administration directed in part that any and all Controlled Substances should be accounted for at each visit.

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 a review of clinical records, review of agency policies and interview with agency personnel, for three of three patient’s (Patient’s #2, #3 & #4) requiring weight monitoring for a diagnosis of congestive heart failure, and for one of four patient’s (Patient #2) requiring blood glucose monitoring for a diagnosis of type II diabetes mellitus, and for one of one patient's (Patient #6) requiring central venous catheter monitoring for hemodialysis, the agency licensed nurses failed to provide the necessary assessments. The findings include: a. Patient #2 had a start of care date of 5/31/23 and diagnoses that included fracture of the condylar process of the mandible, hypertension and type II diabetes mellitus. The physician's orders dated 5/31/23 included nursing services two times a week for assessments, monitoring weights every visit with physician notification of a weight gain of two pounds in twenty-four hours or five pounds in a week and assess blood sugar monitoring at every visit, home health aide services, physical therapy and occupational therapy services. i. Interview and review of LPN #1’s nursing notes dated 6/21/23 and 6/23/23 with the SCS on 7/12/23 at 1:30 PM failed to identify documentation of blood glucose monitoring during these visits. ii. Interview and review of the twice weekly nursing notes from 6/06/23 through 6/29/23 (8 visits) with the SCS on 7/12/23 at 1:40 PM failed to identify documentation of weight monitoring during these visits. b. Patient #4 had a start of care date of 6/29/23 and diagnoses that included Lambert-Eaton syndrome and congestive heart failure. The physician's orders dated 6/29/23 included nursing services three times a week for two weeks and two times a week for six weeks for assessments and monitoring daily weights every visit with nurse notification of a three pound or more weight loss or gain. i. Interview and review of RN #1’s nursing notes dated 7/06/23 and 7/10/23 and RN #2’s nursing note dated 7/08/23 with the SCS on 7/12/23 at 1:50 PM failed to identify documentation of weight monitoring during these visits. a. Patient #3 had a start of care date of 06/16/2023 with diagnosis that included hypertension with heart failure, and peripheral vascular disease. The physician’s orders dated 06/16/2023 included nursing services three times per week for assessments, wound care, and daily weight monitoring. i. Interview and review of Patient #3’s nursing notes dated 06/19/2023, 06/21/2023, 06/23/2023, 06/26/2023, 06/28/2023, and 06/30/2023 with the Supervisor of Clinical Services (SCS) on 07/12/2023 at 1:30 PM, failed to identify the Patient’s weights were monitored in accordance with the physician’s orders. b. Patient #6 had a start of care date of 03/21/2023 with diagnosis that included end stage renal disease requiring hemodialysis and type I diabetes mellitus. The physician’s orders dated 03/21/2023 included nursing assessments once per week. ii. Interview and review of Patient #6’s plan of care dated 03/21/2023 and nursing notes dated 03/22/2023, 03/23/2023, 03/24/2023, 03/25/2023, 03/26/2023, 03/27/2023, 03/28/2023, 03/29/2023, 03/30/2023, 03/31/2023, 04/01/2023, 04/02/2023 and 04/03/2023 with the SCS on 07/12/2023 at 1:30 PM, identified Patient #6 received hemodialysis three times per week and had a Central Venous Catheter (CVC) to the right chest wall (a type of access used for hemodialysis). The SCS failed to identify the monitoring of Patient #6’s CVC was incorporated into the plan of care and failed to identify the CVC was monitored for infection upon each nursing visit.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on review of the clinical record, review of agency policies and interview with agency personnel, for three of three patient’s (Patient’s #2, #3 & #4) requiring weight monitoring for a diagnosis of congestive heart failure, and for one of four patient’s (Patient #2) requiring blood glucose monitoring for a diagnosis of type II diabetes mellitus, the agency licensed nurses failed to ensure the care delivered was in accordance with the physician's orders. The findings include: a. Patient #2 had a start of care date of 5/31/23 and diagnoses that included fracture of the condylar process of the mandible, hypertension and type II diabetes mellitus. The physician's orders dated 5/31/23 included nursing services two times a week for assessments, monitoring weights every visit with physician notification of a weight gain of two pounds in twenty-four hours or five pounds in a week and assess blood sugar monitoring at every visit, home health aide services, physical therapy and occupational therapy services. i. Interview and review of LPN #1’s nursing notes dated 6/21/23 and 6/23/23 with the SCS on 7/12/23 at 1:30 PM failed to identify documentation of blood glucose monitoring during these visits and failed to follow physician’s orders. ii. Interview and review of the twice weekly nursing notes from 6/06/23 through 6/29/23 (8 visits) with the SCS on 7/12/23 at 1:40 PM failed to identify documentation of weight monitoring during these visits and failed to follow physician’s orders. b. Patient #4 had a start of care date of 6/29/23 and diagnoses that included Lambert-Eaton syndrome and congestive heart failure. The physician's orders dated 6/29/23 included nursing services three times a week for two weeks and two times a week for six weeks for assessments and monitoring daily weights every visit with nurse notification of a three pound or more weight loss or gain. a. Interview and review of RN #1’s nursing notes dated 7/06/23 and 7/10/23 and RN #2’s nursing note dated 7/08/23 with the SCS on 7/12/23 at 1:50 PM failed to identify documentation of weight monitoring during these visits and failed to follow physician’s orders. Review of agency policy for Plan of Care directed to include medications and treatments, pertinent diagnoses and patient specific interventions and education. a. Patient #3 had a start of care date of 06/16/2023 with diagnosis that included hypertension with heart failure, and peripheral vascular disease. The physician’s orders dated 06/16/2023 included nursing services three times per week for assessments, wound care, and daily weight monitoring. i. Interview and review of Patient #3’s nursing notes dated 06/19/2023, 06/21/2023, 06/23/2023, 06/26/2023, 06/28/2023, and 06/30/2023 with the Supervisor of Clinical Services (SCS) on 07/12/2023 at 1:30 PM, failed to identify the Patient’s weights were monitored in accordance with the physician’s orders.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on review of the clinical record and interview with agency personnel, for one of one patient (Patient #5) requiring medication management, the Governing Body failed to develop policies for the weekly pre-pouring of medications and the management of Controlled Substances. The findings include: Patient #5 had a start of care date of 7/10/18 and diagnoses that included schizophrenia, anxiety and chronic obstructive pulmonary disease. The physician's orders for the certification periods of 6/14/23 to 8/12/23 included nursing services weekly for pre-pouring medications and assessments. Physician’s orders directed to pre-pour Clonazepam (a Schedule IV controlled substance) 0.5 mg once a day for anxiety. Interview and review of the Supervisor of Clinical Service/SCS weekly nursing notes from 6/18/23 to 7/09/23 (4 visits) with the Regional RN on 7/13/23 at 10:00 AM identified that Clonazepam was pre-poured weekly but failed to identify a controlled substance record was developed as a mechanism for counting the number of tablets of Clonazepam found in the bottle, and the remaining balance of the tablets after the nurse accessed the controlled substance to prevent discrepancies. Interview and review of the SCS weekly nursing notes from 6/18/23 to 7/09/23 (4 visits) with the Regional RN on 7/13/23 at 10:10 AM identified that the patient’s medications were pre-poured weekly but failed to identify documentation of the medications that were pre-poured weekly and the timeframe the medications were pre-poured. Review of agency policy for Medication Orders and Administration directed in part that any and all Controlled Substances should be accounted for at each visit but failed to identify a mechanism for counting Controlled Substances to prevent discrepancies and failed to develop a policy for documenting the pre-pour process to include the “from” and “to” dates the medications are pre-poured.

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 the clinical record and interview with agency personnel, for one of seven patients (Patient #5) in the survey sample, the agency nurses failed to ensure documentation of the pre-pour process was incorporated into the clinical record. The findings include: Patient #5 had a start of care date of 7/10/18 and diagnoses that included schizophrenia, anxiety and chronic obstructive pulmonary disease. The physician's orders for the certification periods of 6/14/23 to 8/12/23 included nursing services weekly for pre-pouring medication and assessments. Interview and review of the SCS weekly nursing notes from 6/18/23 to 7/09/23 (4 visits) with the Regional RN on 7/13/23 at 10:10 AM identified that the patient’s medications were pre-poured weekly but failed to identify documentation of the medications that were pre-poured weekly and the timeframe the medications were pre-poured according to agency expectations. There was no agency policy to review.

Administrator CFR(s): 484.115(a) Standard: Administrator, home health agency. (1) For individuals that began employment with the HHA prior to January 13, 2018, a person who: (i) Is a licensed physician; (ii) Is a registered nurse; or (iii) Has training and experience in health service administration and at least 1 year of supervisory administrative experience in home health care or a related health care program. (2) For individuals that begin employment with an HHA on or after January 13, 2018, a person who: (i) Is a licensed physician, a registered nurse, or holds an undergraduate degree; and (ii) Has experience in health service administration, with at least 1 year of supervisory or administrative experience in home health care or a related health care program. This STANDARD is not met as evidenced by: Based on review of personnel files and an interview with agency personnel, the Administrator failed to meet the necessary qualifications in accordance with federal and Connecticut state regulations. The finding included: Review of the Administrator’s personnel file on 7/13/23 identified the Administrator was in this role from March 2022 until current absent the necessary qualifications. Interview with the Administrator on 07/13/2023 at 12:45 PM, identified the Administrator had not been a licensed or practicing physician since 1996, did not hold a master’s degree in public health or a bachelor’s degree in administration and failed to be trained in health service administration. Additionally, the Administrator had not been continuously employed as a Administrator in the state of Connecticut for more than five years. Subsequent to surveyor inquiry, the agency appointed a new Administrator on 07/14/2023 who met the federal and state regulatory requirements to hold the title of Administrator.