Every finding on record at Visiting Nurse Association of Hanover and Spring Grove, Inc.

Based on the findings of an onsite unannounced home health agency Medicare recertification survey conducted 2/17/2022-2/22/2022, VNA of Hanover and Spring Grove, was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced onsite home health agency Medicare recertification survey conducted 2/17/2022-2/22/2022, VNA of Hanover and Spring Grove, was found to not be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based upon review of agency policy, clinical records (CR), and interview with clinical director (EMP # 1), agency failed to conduct the initial assessment visit within forty-eight (48) hours of referral for three (3) of eleven (11) records reviewed. ( CR # 5; CR # 9; CR # 11). Review of agency policy on 2/22/2022 between approximately 12:00 PM-2:00 PM titled " 4.1 Referral Intake and Evaluation for Acceptance" stated " (4). The initial assessment visit is scheduled to be completed within 48 hours of referral, within 48 hours of the patient's return home, or on the physician-ordered start of care date." Review of clinical records (CR) on 2/18/2022 between 12:30 PM-3:00 PM and 2/22/2022 between 8:00 AM-12:00 PM revealed: CR # 5, Start of Care (SOC) 1/20/2022; referral received 1/12/2022 for this patient to be discharged from facility on 1/16/2022. No documentation produced to explain delay in starting care until ninety-six (96) hours later. CR # 9, SOC 2/4/2022; referral received 1/24/2022 from family practice on 1/24/2022. This patient was admitted to hospital prior to start of services. Discharge from hospital on 2/1/2022 and agency started care for this patient on 2/4/2022 or seventy-two (72) hours later. CR # 11, SOC 2/6/2022; referral received from hospital with discharge date of 2/1/2022. No documentation produced to explain delay in starting care until one hundred and twenty (120) hours later. Interview with EMP # 1 on 2/22/2022 at approximately 2:00 PM confirmed above findings.