Every finding on record at Specialized Nursing Services Inc

During the recertification survey conducted on 08/11/2025 to 08/13/2025 at Specialized Nursing Services Inc., Home Health Agency, Emergency Preparedness was reviewed. Specialized Nursing Services Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.22, Condition of Participation for Home Health Agencies.

A recertification survey was conducted on 08/11/2025 to 08/13/2025 at Specialized Nursing Services Inc. The home health agency was in non-compliance with Code of Federal Regulations (CFR) 484 Subpart A-C, Requirements for Home Health Agencies.

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 review and interview, the home health agency is unable to demonstrate a completed termination summary, including the date of the first visit, discharge date, type of services and frequency and medications the patient is on at the time of discharge, in 2 out of 5 Sampled Patients (SP), SP #4 and SP #5. Findings include: Closed record reviews of Sample Patient (SP) #4 and SP #5 were conducted on 08/11/2025 to 08/13/2025. The clinical record for SP #4 contained a discharge summary from the agency with a discharge date of 04/27/2025; and SP #5 contained a discharge summary from the agency with a discharge date of 05/08/2025. The discharge summaries for SP #4 and SP #5 omitted information such as information such as Admission and discharge date, type of service and frequency, and medications the patient is on at time of discharge. Interview conducted with the Administrator on 08/13/2025 at 03:30pm, acknowledged that the summaries for SP #4 and SP #5 were incomplete, missing the required notations as previously mentioned.

During the recertification survey conducted on 10/17/2022 to 10/20/2022 at Specialized Nursing Services Inc., a Home Health Agency, Emergency Preparedness was reviewed. Specialized Nursing Services Inc. is not in compliance with Emergency Preparedness per Code of Federal (CFR) 42 Part 484.102, Condition of Participation for Home Health Agencies.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on record review and interview, the provider failed to demonstrate that all new and existing staff have received training on the emergency preparedness updated policies and procedures; and the provider is unable to demonstrate that it has conducted emergency preparedness training at least every 2 years with existing staff. (Staff D, Staff E, Staff F, Staff G, Staff H and Staff J) Findings include: Review of the Comprehensive Emergency Preparedness Plan documentation presented by the Administrator and Quality Assurance Registered Nurse on 10/19/22 omitted documentation to demonstrate all active staff have received emergency preparedness initial training (Staff E, Staff F, Staff G, Staff H) and then at least every 2 years (Staff D, Staff E, Staff F, Staff G, Staff H and Staff J). Interview conducted with the Administrator and Quality Assurance Registered Nurse on 10/19/22 at 2:53 PM reviewed the attendance sign in sheet and acknowledged that not all staff have receiving training as required.

A recertification survey was conducted on 10/17/2022 to 10/20/2022 at Specialized Nursing Services Inc. The home health agency was in non-compliance with 42 CFR 484 Subpart A-C, Requirements for Home Health Agencies.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency failed to demonstrate it had obtained the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for 1 out of 10 Sampled Patients (SP). (SP#9) Findings include: Closed clinical record review was conducted from 10/17/22 to 10/19/22. Review of the clinical record for SP#9 revealed that patient was admitted to service with a start of care date of 06/17/22 to receive skilled nursing and physical therapy services. Further review of the clinical record contained no service consent signature page for the admission of 06/17/22. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 12:49 PM. The Administrator reviewed the clinical record for SP#9 and agreed the record omitted the signature consent page.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to document all patient care orders in the Plan of Care for 1 out of 10 Sampled Patients (SP). (SP#6) Findings include: Clinical record review was conducted from 10/17/22 to 10/19/22 for SP #6. A review of the clinical record contained a physician order dated 09/22/22 that reads "Instruct patient to report no output from stoma, pain, vomiting. Instruct patient on low residue diet, to eat very slowly and chew food thoroughly. Instruct patient how to change ostomy appliance every 3-5 days. Instruct patient to empty stool/urine for the pouch once 1/3 to ½ full. Measure stoma with each change. Use barrier ring with each change. Encourage patient to be independent with pouching. Instruct to prevent dehydration by drinking at least 2 liters of water daily and measure stoma output, using the provided out log, for the first 2 weeks after discharge. Report stoma output >1200 ml in a 24 hour period, call [phone number].” Further review of the clinical record revealed the Plan of Care for certification period 09/29/22 to 11/27/22 omitted the order as written on the physician order dated 09/22/22. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 12:25 PM. The Quality Assurance Registered Nurse confirmed the Plan of Care omitted the specific instructions for the ostomy teaching.

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 provider failed to be in conformance with the physician order for 1 out of 10 Sampled Patients (SP). (SP#7) Findings include: Clinical record review was conducted from 10/17/22 to 10/19/22. A Plan of Care for certification period 08/30/22 to 10/28/22 for SP#7 reads "SN (skilled nurse) frequency and orders: 1 x w x 8 weeks (one time a week for eight weeks) as of 09/06/22.” Further review of the clinical record revealed the scheduled visit for the skilled nurse date 09/06/22 showed as “missed visit”, no further skilled nurse visit scheduled. The clinical record omitted documentation reason for not providing skilled nurse as stated on Plan of Care. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 between 12:34 PM and 12:49 PM. Review of the clinical record and documentation present was completed by Administrator, Director of Nursing and Quality Assurance Registered Nurse. The Administrator confirmed that nursing was provided only for Recertification assessment and stated that patient is only receiving Physical Therapy service at present. The Administrator and Quality Assurance Registered Nurse agree that the skilled nursing discipline has not been provided as ordered on the Plan of Care dated 08/30/22. The Administration acknowledged that the ordering physician was not notified in writing that nursing service is not being provided.

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 clinical record review and interview, the provided failed to notify the physician of a review and revision of the plan of care for 1 out of 10 Sampled Patients (SP). (SP#5) Findings include: Clinical record review was conducted from 10/17/22 to 10/19/22. The Plan of Care for certification period 08/27/22 to 10/25/22 for SP#5 reads “SN (skilled nurse) 1 x w x 1 week (one time for one week); Physical Therapy frequency 2 x w x 8 weeks (twice a week for eight weeks); OTE and TX (Occupational Therapy Evaluation and Treatment). Review of the clinical record revealed the patient was provided for Skilled Nursing on 08/27/22; Physical Therapy Evaluation completed on 08/29/22; and Occupational Therapy Evaluation was scheduled for 09/22/22 and documented as missed visit. Further review of the clinical record omitted documentation that the ordering physician was notified of the Occupational Therapy Evaluation missed visit and reason. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 12:17 PM. The Administrator stated that the SP#5 declined the Occupational Therapy service. The Administrator acknowledged that the ordering physician was not notified of SP#5 refusing the Occupational Therapy service. The Administrator confirmed that the occupational therapist never made a visit to conduct the evaluation because the patient refused.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review and interview, the provided failed to alert the relevant physician(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered for 1 out 10 Sampled Patients (SP). (SP#2) Findings include: Clinical record review was conducted from 10/17/22 to 10/19/22. The SP#2 contained a Plan of Care with certification period of 08/30/22 to 10/28/22 that reads Skilled Nurse frequency 1 x w x 5 weeks (one time a week for five weeks) “for assessment of all body system particularly cardiovascular, instruct on diet, medications infection control, diabetic management including foot care and report any abnormal findings to MD (medical doctor)”; Physical Therapy frequency 2 x w x 4 weeks (twice a week for four weeks); Occupational Therapy frequency 2 x w x 7 weeks (twice a week for seven weeks); Speech “Eval and TX” (Evaluation and Treatment). Further record review revealed no Speech evaluation completed as of 10/19/22; the skilled nurse scheduled visits for 09/21/22 and 09/30/22 documented as missed visit; Physical Therapy completed 2 times a week for 2 weeks visits with last made visit dated 09/08/22. The clinical record omitted documentation the physician was notified of the changes to the established plan of care for the services skilled nursing, physical therapy and speech therapy. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 12:03 PM. The Administrator stated that patient requested to hold the PT (physical therapy) service and she refused ST (speech) “didn’t want it at this time”. The Administrator confirmed that the physician was not notified to the changes of the plan of care for the patient.

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 record review and interview, the provider failed to demonstrate that 6 out of 10 active staff received annual in-service on infection control. (Staff A, Staff C, Staff D, Staff E, Staff F, Staff G, Staff H and Staff I) Findings include: Record review revealed the home health agency provided infection control education in-service on 09/30/22 to its employees. Further record review revealed no documentation to show that 8 out of 10 active staff (Staff A, Staff C, Staff D, Staff E, Staff F, Staff G, Staff H and Staff I) participated in the infection control education in-service. During an interview conducted on10/19/22 at 2:53 PM, the Quality Assurance Registered Nurse acknowledged that the (8) active staffs providing nursing, personal care, physical and occupational therapy services have not received infection control education in-service from the provider for in-service date 09/30/22.

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 record review and interview, the home health agency staff failed to provide service(s) that are ordered by the physician as indicated in the Plan of Care (POC) for 1 out 10 Sampled Patients (SP). (SP#10) Findings include: Closed clinical record review conducted from 10/17/22 to 10/19/22 of SP#10 contained a Plan of Care for certification period 07/22/22 to 09/19/22 that under section "Orders and Treatments" reads "SN (skilled nurse) Frequency and Orders: 1 x w x 1 week (one time for one week), 3 x w x 8 weeks (three times a week for eight weeks)”, then “Notify physician of: Temperature greater than (>) 101.5 or less than () 100 or less than () 24 or less than () 180 or less than () 90 or less than () 300 or less than () 300 or less than ( Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 1:15 PM. The Administrator and Quality Assurance Registered Nurse reviewed the Licensed Practical Nurse’s service notes and acknowledged that the nurse failed to document vital signs as established by the physician.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on record review and interview, the home health agency staff failed to provide nursing service within the scope of practice related to patient and caregiver education for 1 out of 10 Sampled Patients (SP). (SP#6) Findings include: Clinical record review was conducted from 10/17/22 to 10/19/22. A review of the clinical record of SP#6 contained a physician order dated 09/22/22 that reads "Instruct patient to report no output from stoma, pain, vomiting. Instruct patient on low residue diet, to eat very slowly and chew food thoroughly. Instruct patient how to change ostomy appliance every 3-5 days. Instruct patient to empty stool/urine for the pouch once 1/3 to ½ full. Measure stoma with each change. Use barrier ring with each change. Encourage patient to be independent with pouching. Instruct to prevent dehydration by drinking at least 2 liters of water daily and measure stoma output, using the provided out log, for the first 2 weeks after discharge. Report stoma output >1200 ml in a 24 hour period, call [phone number].” Further review of the clinical record for date range 09/30/22 to 10/11/22 revealed the Registered Nurse omitted documentation of teaching on ostomy care and complications to be reported to the physician; no documentation on each visit made by the Registered Nurse that the output was being assessed and of the stoma being measure at each change. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 12:25 PM. The Quality Assurance Registered Nurse reviewed Registered Nurse notes and confirmed that the nurse service notes do not reflect ostomy teaching as ordered by the physician.

Direct observation every 12 months CFR(s): 484.80(h)(1)(iii) A registered nurse or other appropriate skilled professional must make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This ELEMENT is not met as evidenced by: Based on record review and interview, the provider failed to make an annual on-site visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care for 1 out of 2 employee record review. (Staff I) Findings include: Review of personnel records conducted on 10/19/22 to 10/22/22 for Staff I contained a titled document "Annual Evaluation". Further review of the documentations for Staff I omitted documentation of the evaluation being done onsite while the aide performed care to a patient. Interview conducted with the Human Resource Staff and Director of Nursing on 10/20/22 at 12:30 PM reviewed documentation presented and confirmed the annual evaluation was conducted in the office; unable to demonstrate the supervision was conducted onsite while the aide provided care to a patient.

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 clinical record and interview, the provider failed to ensure the clinical record included 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 home health agency becomes aware of the transfer for 1 out of 10 Sampled Patient (SP). (SP#4) Findings include: Clinical record review was conducted from 10/17/22 to 10/19/22. The Plan of Care for certification period 09/22/22 to 11/20/22 order for SP#4 to receive Skilled Nurse service to be provided daily for wound care and monthly urinary device change. On 09/26/22 the patient was transferred to the hospital. Further review of the clinical record omitted documentation that a transfer summary was sent within 2 business days of becoming aware of an unplanned transfer. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 12:17 PM. The Administrator confirmed that the transfer summary was faxed only to the ordering physician and acknowledged that provider did not send transfer summary to the admitting facility.

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 record review and interview, the provider failed to ensure the clinical record includes all entries appropriately authenticated (signature and a title), dated, and timed for 1 out 10 Sampled Patient (SP). (SP#3) Findings include: Clinical record review was conducted from 10/17/22 to 10/19/22. The Plan of Care for SP#3 ordered skilled nursing service 5 times a week for wound care. Review of the electronical clinical record for date range 06/25/22 to 07/01/22, 07/06/22 to 08/17/22, 08/23/22 to 09/20/22, 09/23/22, and 10/11/22 to 10/12/22 showed the clinical notes were completed by the same name staff and further review revealed all notes omitted the title of the staff. Interview was conducted with Administrator, Director of Nursing and Quality Assurance Registered Nurse on 10/19/22 at 12:09 PM. The Administrator reviewed the skilled nurse notes and confirmed no titles on the notes. The Administrator confirmed the skilled nurse title is Licensed Practical Nurse.