Every finding on record at Visiting Nurse Association of Indiana County

Based on the findings of an onsite unannounced complaint survey completed 10/1/2025, Visiting Nurse Association Of Indiana County was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on review of agency policy, job descriptions, Medical records (MR), and staff (EMP) interview, it was determined that the agency failed to ensure wounds were measured weekly for one (1) of four (4) MR's reviewed. (MR2 ). Findings included: Review of agency training guidance on 9/17/2025 at approximately 3:25 PM revealed, “Wound Cre: Assessment and Measurement…*gather your supplies, perform hand hygiene, and don clean gloves. *Place supplies, such as a plastic shaft applicator, gauze, and penlight, on a clean drape or field. *Ensure adequate lighting is present…Step 4: Inspect the Wound *Visually inspect the wound, and use a penlight or flashlight to see all aspects of the wound. Step 5: Measure the Wound *Use a plastic shaft applicator to measure the wound, measuring length as the longest area from head to toe, width as the longest area horizontally, and depth as the deepest area in relation to the wound margin. *Note that best practice is to use centimeters. Step 6: Measure Tunnels *Place the applicator in the tunnel. The measurement will be from the base to where it begins. *To measure undermining, you want to use the deepest areas of undermining and document it using clock terminology, such as 3 centimeters of undermining is noted at 3 o’clock. *Document your measurements at least once a week. Step 7: *Assess wound tissue and determine the percentage of granular, necrotic, and nongranulating tissue. *Document what percentage of each kind of tissue you see. *Assess the periwound tissue. *You may use an applicator or gloved finger to feel the tissue in the wound or to feel if bone is present or close to the wound bed…” Review of agency policy on 10/1/2025 at approximately 1:00 PM revealed, “POSITION DESCRIPTION-REGISTERED NURSE…POSITION SUMMARY… The Registered Nurse is a licensed health care professional with advanced medical knowledge who administers skilled nursing care to patients requiring intermittent visits. She/he provides complex care to the patient and coordinates necessary support services. These nursing services are provided to patients in accordance with a physician’s plan of care. Registered Nurses who serve as primary nurses utilize a case manager approach in assessing, implementing, coordinating, and evaluating client care. Additionally, the Registered Nurse manages other members of the nursing team. The Registered Nurse provides care consistent with all relevant professional standards and state and federal regulations. A. Provides skilled nursing care that includes activities such as teaching, treatments, (including IV therapy, venipuncture, complex wound care) and health promotion practices…S. Meets with Clinical Supervisor or Case Manager weekly for an evaluation of patients under his/her care…” Review of agency policy on 10/1/2025 at approximately 1:00 PM revealed, “POSITION DESCRIPTION-LICENSED PRACTICAL NURSE…POSITION SUMMARY The Licensed Practical Nurse (LPN) works under the guidance of the Registered Nurse (RN) as a member of a team to give direct nursing care to patients requiring intermittent visits. The LPN collaborates patient care with the case managing RN, physician, and patient and follows a patient specific treatment plan. The LPN provides care consistent with all relevant professional standards and state and federal regulations…DUTIES AND RESPONSIBILITIES Clinical Skills A. Provides skilled nursing care that includes activities such as teaching and treatments (including IV therapy- if IV certified, venipuncture and complex wound care) and health promotion practices…F. Documents all communications with the physician and the interdisciplinary team on the patient’s electronic health record…” Review of MR2 was conducted on 9/17/2025 at approximately 2:52 PM revealed, "Home Health Certification and Plan of Care" with a start of care date of 5/9/2025 and a certification period starting 5/9/2025 and ending 7/7/2025. The primary diagnosis was encounter for surgical aftercare following surgery on the genitourinary system. Wound assessments were review from the date’s visits were conducted: 5/9/2025 Measurements documented 5/12/2025 No measurements 5/14/2025 No measurements 5/16/2025 No measurements 5/18/2025 No measurements 5/20/2025 No measurements 5/22/2025 No measurements 5/24/2025 No measurements 5/26/2025 Measurements documented 5/28/2025 Measurements documented 5/30/2025 Refused measurements An exit interview was conducted with the quality manager on 9/17/2025 at approximately 3:45 PM which confirmed the above findings.

Based on the findings of an unannounced complaint survey conducted onsite 12/8/2023 and completed offsite 12/19/2023, Visiting Nurse Association Of Indiana County was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Transfer and discharge CFR(s): 484.50(d) Standard: Transfer and discharge. The patient and representative (if any), have a right to be informed of the HHA's policies for transfer and discharge. The HHA may only transfer or discharge the patient from the HHA if: This STANDARD is not met as evidenced by: Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide notify the patient of termination of services prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide notify the patient of termination of services prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Findings Included: Review of the departments policy was conducted on 12/8/2023 between approximately 10:35 AM which revealed, “SUBJECT: Discharge Policy I. Policy All (Agency) patients/patient representative are involved in the coordination of discharge from the Agency. II. Procedure A. Discharge Planning begins with the admission visit. B. The discharge plan with effective date is developed cooperatively with the patient/patient representative. C. Clinical staff, in cooperation with the patient’s physician, evaluates patient progress toward established goals and works together with the patient/patient representative for a timely discharge based on patient status. D. Discharge occurs in the following situations: 1. The patient reaches maximum rehabilitation and /or clinical status no longer requires skilled care…E. Discharge planning steps are documented in the patient clinical record. *The physician and other relevant providers of care are notified of the patient’s discharge from service. Agency Standards for Care require a Discharge Summary to be written for HomeHealth patients and sent to physician within the timeframe specified by Federal Regulations. F. The discharge Summary includes: *Date of admission and discharge *Physician responsible for the home health plan of care *Reason for admission to home health *Types of services provided and frequency of services *Medications the patient is on at time of discharge *Status of problems identified throughout the course of care, including, as appropriate, physical/psychosocial status, goals achieved, patient/family teaching, lab/vital signs parameters.” Review of MR3 was conducted on 12/8/2023 at approximately 1:00 PM which revealed, start of care 10/5/2023 with a certification period of 10/5/2023 to 12/3/2023, the last visit conducted by agency staff was on 10/20/2023. MR3 was discharge from nursing services on 10/18/2023. No documentation was provided to confirm the patient was discharge from the agency. No documentation was provided to confirm the patient or patient representative was provided agency documents “Discharge Planning Guide, Discharge Instructions (or) Therapy Discharge Instructions,” upon termination of services. An interview was conducted with the executive director and quality assurance staff member on 12/8/2023 at approximately2:15 PM which confirmed the above findings.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide separation information to the patient prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to provide separation information to the patient prior to separation from the agency for one (1) of four (4) MR reviews conducted (MR3). Findings Included: Review of the departments policy was conducted on 12/8/2023 between approximately 10:35 AM which revealed, “SUBJECT: Discharge Policy I. Policy All (Agency) patients/patient representative are involved in the coordination of discharge from the Agency. II. Procedure A. Discharge Planning begins with the admission visit. B. The discharge plan with effective date is developed cooperatively with the patient/patient representative. C. Clinical staff, in cooperation with the patient’s physician, evaluates patient progress toward established goals and works together with the patient/patient representative for a timely discharge based on patient status. D. Discharge occurs in the following situations: 1. The patient reaches maximum rehabilitation and /or clinical status no longer requires skilled care…E. Discharge planning steps are documented in the patient clinical record. *The physician and other relevant providers of care are notified of the patient’s discharge from service. Agency Standards for Care require a Discharge Summary to be written for Home Health patients and sent to physician within the timeframe specified by Federal Regulations. F. The discharge Summary includes: *Date of admission and discharge *Physician responsible for the home health plan of care *Reason for admission to home health *Types of services provided and frequency of services *Medications the patient is on at time of discharge *Status of problems identified throughout the course of care, including, as appropriate, physical/psychosocial status, goals achieved, patient/family teaching, lab/vital signs parameters.” Review of MR3 was conducted on 12/8/2023 at approximately 1:00 PM which revealed, start of care 10/5/2023 with a certification period of 10/5/2023 to 12/3/2023, the last visit conducted by agency staff was on 10/20/2023. MR3 was discharge from nursing services on 10/18/2023. No documentation was available to confirm the patient or patient representative was provided with information including contact numbers for other community resources and names of other agencies or providers that may be able to provide services to the patient upon discharge. An interview was conducted with the executive director and quality assurance staff member on 12/8/2023 at approximately2:15 PM which confirmed the above findings.

Based on the findings of an on-site unannounced Medicare recertification and state relicensure survey completed 11/17/2023, Visiting Nurse Association of Indiana County was found not to be in compliance with the following requirement of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Policies/Procedures-Volunteers and Staffing CFR(s): 484.102(b)(5) §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This STANDARD is not met as evidenced by: Based on a review of the facility Emergency Disaster Preparedness Plan and staff (EMP) interview, it was determined the facility failed to develop and maintain a procedure for the use of volunteers in an emergency or emergency staffing strategies. Findings Included: Review of the facility Emergency Disaster Preparedness Plan was conducted 11/16/2023 at approximately 10:05 AM. Facility plan did not contain documented evidence of a procedure for the use of volunteers. An exit interview was conducted with the executive director, quality compliance and education staff member, director of compliance and education, quality manager and home health manager on 11/17/2023 at approximately 3:00 PM which confirmed the above findings.

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed on 11/17/2023, Visiting Nurse Association of Indiana County was found not to be in compliance with the following requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on a review of agency policy, medical record (MR), observation (OBV) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking, and identify and address potential adverse effects, drug reactions, significant side effects and drug interactions for two three (3) of seventeen (17) MR's reviewed (MR3, MR6 and MR10). Based on a review of agency policy, medical record (MR), observation (OBV) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking, and identify and address potential adverse effects, drug reactions, significant side effects and drug interactions for two three (3) of seventeen (17) MR's reviewed (MR3, MR6 and MR10). Findings Included: Review of the agency policy and procedures was conducted on 12/01/2023 at approximately 1:00 PM which revealed, “SUBJECT: Medication Administration…*Procedure…G. Administration safeguards are utilized such as reviewing allergy history, assuring correct labeling, checking expiration date and medication stability, and evaluating patient prior to administration…K. The clinical record of the patient includes: A complete medication profile to include but not be limited to allergies to both food and drugs; medication history; patient’s knowledge of the purposed and significant side effects of the prescribed drug; appropriate dosage; contraindications; effectiveness of the drug; awareness of potential adverse effects; route of administration; use of over the counter drugs; and cognitive status…” Review of MR3 (OBV3) medication list were compared on 11/17/2023 at approximately 2:20 PM revealed, "Home Health Certification and Plan of Care" with a start of care date of 9/8/2023 and a current certification period starting 11/7/2023 and ending 1/5/2024. The primary diagnosis was pressure ulcer of right ankle, unstageable. The Home Health Certification and Plan of Care and Client Medication Report listed, "Allergies: PENICILLIN” was compared to the facilities “MAR." which listed "...ALLERGIES PENCILLINS, SULFA (SULFONAMIDE ANTIBIOTICS)." The allergies documented on the forms did not match. Review of MR5 (OBV5) medication list were compared on 11/17/2023 at approximately 2:20 PM. The agency’s document "Home Health Certification and Plan of Care" had a start of care date of 11/3/2023 and a current certification period starting 11/3/2023 and ending 1/1/2024. The primary diagnosis was other iron deficiency anemias. The Home Health Certification and Plan of Care and Client Medication Report was compared to the facilities “MAR." The following two (2) medications were not listed on the on the agency documents. "ACETAMINOPHEN (MAPAP) 500MG...Date Written: 1-Nov-2023…" "NITROGLYCERN SUB 0.4MG...Date Written: 3-Nov-2023…" The following medication was not listed on the on the agency's client medication report. "METOPROLOL TARTRATE 100 MG TABLET…Start Date/End Date 11/03/2023…" Review of MR10 was conducted on 11/16/2023 at approximately 1:40 PM which revealed: The agency’s document "Home Health Certification and Plan of Care" had a start of care date of 6/12/2021 and a current certification period starting 9/30/2023 and ending 11/28/2023. The primary diagnosis was Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease. The Home Health Certification and Plan of Care and Client Medication Report (date 11/14/2023) was compared to a physician’s report (fax date 6/11/2021). The Client Medication Report listed Client Allergies as follows: “APIXABAN, ASPIRIN, CARBAMAZEPINE, GABAPENTIN, HYDROCONONE BITARTRATE, HYDROXYCHLOROQUINE, LAMOTRIGINE, MORPHINE, NITROUS OXIDE, PENICILLINS, WARFARIN, ZITHROMAX.” The physician’s report listed allergies as follows: Allergies, Allergen, Morphine…Apixaban…Asprin…Carbamazepine…Gabapentin…Hydroxychloroquine…Hysingla Er [Hydrocodone Bitartrate]…Lamotrigine…Nitric Oxide…Nitro Transdermal …Penicillins…Warfarin…” The medication allergy “Nitro Transdermal” was not listed on the agency client medication report. An exit interview was conducted with the executive director, quality compliance and education staff member, director of compliance and education, quality manager and home health manager on 11/17/2023 at approximately 3:00 PM which confirmed the above findings.

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 review of agency policy and procedure, observations (OBV) during home visits and staff (EMP) interview, the agency failed to ensure staff followed infection control standards of practice and agency policy and procedure for four (4) of seven (7) observations where staff was providing direct care to patients (OBV1, OBV3, OBV5 and OBV7). Findings Included: Review of the agency policy and procedures was conducted on 12/01/2023 at approximately 1:00 PM which revealed, Document provided by agency for nursing/supply bag technique “Skills: Supply Bag Technique (Home Health Care) PROCEDURE Preparing the Bag…2. Create a dedicated area of the bag for clean, reusable items (e.g., blood pressure cuff). 3. Create a dedicated area of the bag for clean, sterile, nonreusable items, such as dressings and supplies. 3. When reentering the home, place the bag on a clean, dry surface with a water-resistant barrier placed between the bag and the surface…” Obversions (OBV1) on 11/17/2023 at approximately 9:25 AM patient care was conducted for (MR1) revealed, EMP5 provided direct patient care. EMP5 placed two chuck/barrier on a couch with the nursing/supply bag on top of one of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier onto the front of the couch. Obversions (OBV3) on 11/17/2023 at approximately 9:42 AM patient care was conducted for (MR3) revealed, EMP7 provided direct patient care. EMP7 placed a chuck/barrier on a chair with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier against the side of the chair. Obversions (OBV5) on 11/17/2023 at approximately 10:47 AM patient care was conducted for (MR5) revealed, EMP9 provided direct patient care. EMP9 placed a chuck/barrier on a chair with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier against the side of the chair. Obversions (OBV7) on 11/17/2023 at approximately 12:47 PM patient care was conducted for (MR7) revealed, EMP11 provided direct patient care. EMP11 placed two chuck/barrier on a couch with the nursing/supply bag on top of the chuck/barrier. Part of the strap from the nursing/supply bag was laying off the side of the chuck/barrier onto the side of the couch. An exit interview was conducted with the executive director, quality compliance and education staff member, director of compliance and education, quality manager and home health manager on 11/17/2023 at approximately 3:00 PM which confirmed the above findings.