Every finding on record at Vana Home Health Inc

Purpose: A complaint/ licensure complaint (RS Case No. 1043381) was entered on 7/20/2026. Census: 53 L&C- 20 LHH- 0 PAS- 33 Abbreviations: Admin- Administrator Alt Admin- Alternate Administrator DON- Director of Nursing GERD- Gastrointestinal Reflux Disease L&C- Licensed and Certified LHH- Licensed Home Health LVN- Licensed Vocational Nurse PAS- Provider Assistance Services Pt- Patient

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to include all the clinical notes in the patients clinical record in 3 of 5 patients (Pt 1, Pt 2, Pt 3) whose records were reviewed. This failure resulted in incomplete and untimely clinical documentation, preventing the agency from demonstrating that services provided were accurately and promptly documented in the patient record. Findings include: Record review of Pt 1’s clinical record revealed a start of care date of 2/2/2026 and a certification period of 4/3/2026-6/1/2026 was reviewed. Pt 1 had a diagnosis of GERD (a condition where stomach acid flows backward into the tube connecting your mouth and stomach) and was ordered to receive skilled nursing visits 1 time a week for 9 weeks. Additional skilled nursing orders included: obtaining vital signs (measuring blood pressure, body temperature, heart rate), monitor food and water intake, and educating Pt 1 on GERD. Review of clinician visit schedule for a period of 4/3/2026-5/2/2026 revealed skilled nursing visits scheduled for 4/9, 4/16, 4/23, 4/30 with a status of “Still Due” listed for each. Review of clinician visit schedule for a period of 6/2/2026-7/1/2026 revealed skilled nursing visits scheduled for 6/4, 6/11, 6/18, 6/25 with a status of “Still Due”. Each visit date revealed no evidence of the nurse performing documentation for these visits. Record review of Pt 2’s clinical record revealed a start of care date of 1/5/2026 with a primary diagnosis of GERD and was ordered to receive skilled nursing visits 1 time per week for 9 weeks. Additional skilled nursing orders included: vital signs (measuring blood pressure, body temperature, heart rate) and educating Pt 2 on GERD. Review of clinician visit schedule for period June 2026 revealed skilled nursing visit scheduled for 6/25 with a status of “Still Due” listed for this visit. Review of clinician visit schedule for July 2026 revealed skilled nursing visits for 7/9, 7/16 scheduled with a status of “Still Due”. Each visit date revealed no evidence of the nurse performing documentation for these visits. Record review of Pt 3’s clinical record revealed a start of care date of 3/24/2026 with a primary diagnosis of osteoarthritis (wear and tear of the cushion on the ends of bones causing the bones to rub against each other). Skilled nursing visits were ordered 2 times per week for 1 week and 1 time per week for 8 weeks. Additional skilled nursing orders included: vital signs (measuring blood pressure, body temperature, heart rate), educating Pt 3 on osteoarthritis, and monitoring food and water intake. Review of clinician visit schedule for May 2026 revealed a skilled nursing visit scheduled for 5/27 with a status of “Still Due” listed for this visit. Review of scheduled for June 2026 revealed skilled nursing visits scheduled for 6/3, 6/10, 6/17 with a status of “Still Due” listed for each visit. Each visit date revealed no evidence of the nurse performing documentation for these visits. Record review of LVN A employment file revealed a hire date of 5/7/2020. Employee evaluations were completed on 8/7/23, 8/7/24, and 8/27/25. Employee record revealed no disciplinary action or documentation of incomplete visit notes being addressed. A phone interview with Pt 2 on 7/21/26 at 3:50 PM was conducted. Pt 2 stated her nurse always shows up for scheduled appointments and that she loved the care that he provided. Pt 2 expressed no concerns with the skilled nursing services that she was receiving from the agency. During an interview with agency Alt Admin on 7/20/26 at approximately 2:30 PM, Surveyor asked Alt Admin why the nursing notes were missing on so many visits and if she had confirmed that visits were being made. Alt Admin stated the reason she was given by LVN A for notes not being complete was that he is often tired at the end of the day. Alt Admin stated the expectation is nursing notes are completed in a timely manner. Alt Admin stated it is the responsibility of the DON/ Admin to ensure that patient notes are submitted in a timely manner. Admin was not available for interview at this time due to physical limitations. An interview with LVN A on 7/21/26 approximately 12:00 PM was conducted. Surveyor asked LVN A why he was not entering nursing notes on the patients that he was seeing. LVN A stated that sometimes he has internet issues and can’t complete the nursing notes. Review of agency policy titled “Medical Record Information Timeline”, revised 5/1/14, read in part, “…daily progress notes are turned in every 7 days and incorporated into the medical record within 14 business days. Notes will be written day of service…”.