Every finding on record at Visiting Nurse Association of Indian River County Inc

During the Recertification survey commenced on 01/25/2022 and concluded on 01/27/2022 at Visiting Nurse Association Of Indian River County, Inc., a Home Health Agency, Emergency Preparedness was reviewed. Visiting Nurse Association of Indian River County, Inc. is in compliance with Emergency Preparedness per Code of Federal Regulations (CFR) 42, Part 484.102, Condition of Participation for Home Health Agencies.

An unannounced Recertification survey was commenced on 01/25/2022 and concluded on 01/27/2022 at Visiting Nurse Association of Indian River County, Inc., Home Health Agency provider, located at 1110 35th Lane, Vero Beach, FL 32960. The Home Health Agency was not in compliance with 42 CFR Part 484 Subpart A-C, Conditions of Participation for Home Health Agencies.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure care follows the written plan of care for 1 of 15 active sampled patients as evidenced by the failure to complete the Occupational Therapy (OT) evaluation as physician ordered (Patient #3). The findings included: Review of the record revealed Patient #3 was admitted to the Home Health Agency (HHA) on 01/13/22. Review of the physician signed plan of care for the certification period of 01/13/22 through 03/13/22 documented the Occupational Therapy (OT) services were to begin during the first week of service. Review of the completed home visits lacked any OT visit during the first week of service. The OT Evaluation was completed on 01/25/22, during the third week of services. During a telephone interview on 01/26/22 at 12:16 PM, Staff B, the OT who completed the evaluation the previous day, was asked why the evaluation was not completed during the first week of service as ordered on the plan of care; Staff B stated she received the assignment on 01/25/22 and was wondering the same thing; Staff B explained if she calls to schedule a patient visit and the patient declines, she would call the physician, write a progress note and obtain an order for a new visit. The Director of Clinical Services (DCS) was made aware of the failure to follow the plan of care related to the lack of the initial OT visit and on 01/26/22 at 3:59 PM, during an interview, the DCS did some "research" and stated the initial OT evaluation visit for Patient #3 was scheduled with Staff B originally during the first week of service, but for an unknown reason it was not completed until 01/25/22.

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 record review and interview, the Home Health Agency (HHA) failed to ensure tube feeding amounts for 1 of 1 sampled patients was provided only as the physician ordered (Patient #15). The findings included: Review of the record revealed Patient #15 was admitted to the HHA on 11/22/21. Further review of the record revealed Patient #15 was admitted to the hospital on 12/15/21, and returned home with physician's orders for tube feedings at 65 ml/hr. (milliliters/hour) for 16 hours. These resumption orders also included home visits by a Registered Dietician (RD). Review of a "progress note," dated 01/04/22 by the ARNP (Advanced Registered Nurse Practitioner) documented to continue tube feedings as prescribed by the RD. Review of a "progress note," dated 01/07/22 by the RD documented the tube feeding had been increased to 67 ml/hr. The record lacked any evidence of a physician's order for the change in the tube feeding rate and this same note documented the RD recommended the rate of the tube feeding for Patient #15 be increased to 75ml/hr for the 16 hours. Review of a "Skilled Nursing progress note," dated 01/11/22 documented the tube feeding had been increased to 75 ml/hr. The record lacked any evidence of documentation of a physician's order for the change in the tube feeding rate. During an interview on 01/27/21 at approximately 4:15 PM, the Director of Clinical Services agreed with the lack of physician's orders related to the changes in the rate of the tube feedings for Patient #15.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure verbal physician's orders for 2 of 15 active sampled patients were complete and written by the nurse (Patient #6 and #7). The findings included: 1) Review of the record revealed Patient #6 was admitted to the Home Health Agency (HHA) on 12/27/21. Review of the plan of care for the certification period of 12/27/21 through 02/24/22 lacked any physician's orders for wound care. Further review of the record revealed a verbal telephone order dated 01/10/22 that documented the skilled nurse was to cleanse the Stage 2 pressure sore with Normal Saline and cover with a foam border dressing three times weekly until healed. Further review revealed this "order" lacked any documented location of the pressure ulcer; documented the Skilled Nurse was to educate the caregiver to reposition the patient every two hours and lacked instructions to teach and or allow the caregiver to do the wound care. Review of the "Skilled Nursing Visit," dated 01/10/22 by Staff C, a Registered Nurse (RN), documented a new Stage 2 pressure ulcer to the right buttock in the narrative, but documented left buttock under the wound care section and right buttock in the patient diagram. During a telephone interview on 01/27/22 at 11:09 AM, Staff C, the RN, confirmed Patient #6 had a pressure ulcer to the right buttock; acknowledged the verbal order for care should include the location of the wound and the RN continued to explain that the patient's spouse was doing the wound care on "non-skilled nurse" visit days. 2) Review of the record revealed Patient #7 was admitted to the HHA on 12/22/21. Review of the plan of care for the certification period of 12/22/21 through 02/19/22 instructed the skilled nurse to obtain a PT/INR (blood coagulation level) on Mondays and Thursdays, and report the results to the physician. Further review of the record revealed Patient #7 went to the Emergency Room (ER) on 01/07/22 related to an abnormally high PT/INR level and a low urine output. Review of the record lacked any verbal physician's order for the transfer. During a phone interview on 01/27/22 at 11:58 AM, Staff D, a Licensed Practical Nurse (LPN), confirmed she did a home visit for Patient #7 on 01/07/22; the LPN explained the PT/INR level was very high, even after checking it a second and third time, so she called the physician and spoke with one of the physician's staff; Staff D, the LPN, stated she could hear the physician in the background telling her to send the patient to the ER (Emergency Room); When asked if she wrote the verbal order for the transfer to the ER, the LPN explained she was new to Home Health, but she was taught during orientation to write (physician's) orders related to the PT/INR testing changes, but didn't realize she had to write other orders from the doctor.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on interview, record review, and review of the Home Health Agency's job description, the Social Worker failed to coordinate and provide requested information for housekeeping services to meet the needs for 1 of 4 sampled patients requiring Medical Social Worker (MSW) assistance (Patient #2). The findings included: Review of the record revealed Patient #2 was admitted to the Home Health Agency (HHA) on 01/02/22 for services to include Medical Social Worker (MSW). Review of the plan of care for the certification period of 01/02/22 through 03/02/22 documented the physician's order for the MSW visit during the first week of service. During a telephone interview on 01/25/22 at 3:38 PM, Patient #2 sounded and voiced she was "frustrated;" Patient #2 explained that she gets out of breath easily, is "tied to this Oxygen," and is unable to clean her home; Patient #2 stated she needs a "cleaning lady;" Patient #2 confirmed that a social worker did see her a few weeks earlier and told her she may know someone who cleans homes and would get back to her with a contact number and Patient #2 stated the social worker never got back to her. Review of the MSW visit dated 01/03/22 by Staff A, a Social Worker documented, "Patient cannot physically perform housekeeping … Patient requests/needs assistance in accessing provider/homemaker services. … Patient with somber, flat disposition. Patient with some depression due to health issues and lack of independence. Patient feeling sad due to inability to do things she used to. … Lives alone. … Indicate other community resource: Housekeeping assistance." During an interview on 01/26/22 at 10:10 AM, Staff A, the Social Worker, discussed her visit with Patient #2 and stated the patient could use private duty services for housekeeping; when asked how that was facilitated, the social worker stated, "Often, they don’t want a company but a private person, as it's less expensive. Except for licensed/insured companies, Staff A stated she doesn’t have the resources; the MSW continued and volunteered that some patients ask if she knows anyone that she could recommend; when asked specifically about Patient #2, the MSW confirmed she had mentioned to the patient that she knew a housekeeper and could provide the patient with a telephone number; when asked if she provided the telephone number to Patient #2, she stated she doesn’t think she did so; Staff A stated she forgot to get back with her, but would call her right now and give her that telephone number and Staff A again confirmed Patient #2 needed housekeeping assistance. Review of the Home Health Agency's signed job description titled, "Social Worker BSW" for Staff A dated 02/23/21 documented, "Essential Job Duties/Responsibilities: … 2. Completes psychosocial assessment of patient and develops a plan for intervention, based on ongoing assessment of needs. … 4. Refers patients/families to appropriate community resources, both locally and nationally."