Every finding on record at Visiting Nurse Association of Manchester & Southern New Hamphsire Inc

An Emergency Preparedness Survey was conducted on 3/25/25 pursuant to the Emergency Preparedness Regulations as referenced in the Centers for Medicare and Medicaid State Operations Manual, 42 CFR Part 484.102 Appendix Z - Rev. HHA Issued: 04/16/21 with no deficiencies cited.

A Health Recertification Survey was conducted from 3/25/25 through 3/26/25, pursuant to 42 CFR Part 484, for Home Health Agencies with deficiencies cited.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, it was determined that the facility failed to submit Outcome and Assessment Information Set (OASIS) assessments timely for 118 records out of 6602 assessments between 3/21/2024 through 3/21/2025. Findings include: Review on 3/24/25 of the Center for Medicare and Medicaid Services (CMS) "HHA [Home Health Agency] Error Summary by Agency" Report for the time frame of 3/21/2024 through 3/21/2025, revealed the following error "-3330 Record Submitted Late: The submission date is more than 30 days after M0090 on this new record" was noted for 118 records out of 6602 assessments. Interview on 3/26/25 at approximately 11:30 a.m. with Staff B (Director of Quality) confirmed the above finding. Staff B revealed that 69 of the 118 assessments were submitted late and 49 of the 118 assessments were submitted late due to demographic changes made.

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 interview and record review, it was determined that the Home Health Agency (HHA) failed to ensure medical records were complete for 2 of 4 patients reviewed for urinary tract infections. (Patient identifiers are #9 and #14.) Findings include Patient #9 Review on 3/25/25 of Patient #9’s medical record revealed the following notes and orders: On 6/28/24, a Case Communication Note by Staff C (Registered Nurse (RN)), stating a call was placed to Patient’s #9’s provider for a physician’s order for a urinary culture. This note did not contain the reason for the requested order. On 6/28/24, a Skilled Nurse Home Visit Note by Staff C, under Infection Assessment read “Does the patient have a confirmed infection, or symptoms of a suspected infection?” and it was answered “none”. On 7/5/24, a Case communication Note by Staff C, stated a call was placed to Patient #9’s provider to ask if a urine culture could be ordered due to recent urinary tract infections. On 7/6/24, a physician’s order to obtain the urine culture for Patient #9 on the next visit. On 7/12/24, a Laboratory Requisition Form from the Home Health Agency that stated the urine specimen was done and sent to the lab for Patient #9. On 7/12/24, a Skilled Nurse Home Visit Note by Staff C under Infection Assessment read “Does the patient have a confirmed infection, or symptoms of a suspected infection?” and it answered “none”. On 7/17/24, a Skilled Nurse Home Visit note by Staff D (Licensed Practical Nurse (LPN)), noted that the patient had a confirmed urinary infection reported on 7/17/24 with a “start” date of 7/16/24 and “end” date of 7/22/24. Further review under Med Management noted the patient was not on any new medications within the past month. There was a care plan starting 5/27/24 for “High Risk for Urinary Tract Infection” with one intervention to educate. There was no documentation in the patient’s record of the results of the urine laboratory results or if the patient had been started on antibiotics. Interview on 3/25/25 at 10:55 a.m. with Staff A (Clinical Manager) confirmed there was no documentation of the results of the urine in the medical record and could not tell if the patient had been started on antibiotics. Patient #14 Review on 3/26/25 of Patient #14’s medical record revealed the following notes and orders: On 2/28/25, a Lab Requisition Form that stated a urine was collected for Patient #14 by Staff D. On 2/28/25, a Skilled Nurse Home Visit note by Staff D, under Infection Assessment read “Does the patient have a confirmed infection, or symptoms of a suspected infection?”, it was answered “none”. On 3/4/25, a Skilled Nurse Home Visit note by Staff F (RN), noted that the patient had a confirmed urinary infection on 3/4/25 and that Patient #14’s antibiotics needed to be picked up. On 3/6/25, a Remote Monitoring note by Staff G (RN), noted that the patient had started antibiotics on 3/5/25. On 3/7/25, a Skilled Nurse Home Visit Note by Staff E (LPN), that revealed that under Infection Assessment read “Does the patient have a confirmed infection, or symptoms of a suspected infection?” was answered “none”. There was no documentation that Patient #14 has started antibiotic. Interview on 3/26/25 at 1:45 p.m. with Staff E revealed that he/she did not think that Patient #14 was treated for the above infection. Interview on 3/26/25 at approximately 1:50 p.m. with Staff A confirmed that it was not clear if the patient was started on antibiotic and that the documentation should have included why the urine culture was being done/infection and/or antibiotic. Review on 3/27/25 of Skilled Nurse Remote Monitoring notes revealed on 3/5/25 that Patient #14 was to start on an antibiotic for a urinary tract infection (UTI). Further review on 3/6/25 revealed that Patient #14 started antibiotic for a UTI on 3/5/25. Review on 3/26/25 of the facility’s undated policy “Medication Reconciliation” revealed, “… Home Health and Hospice patients taking prescribed medications will have a current, accurate medication profile in the clinical record. The EMR [Electronic Medical Record] will be updated or each change to the medication profile to reflect current medications and new and/or discontinued medications… 5. During subsequent visits, clinician will ask if there have been any changes in medications (additions or deletions) since the last visit and reconciling with the current profile. 6. During subsequent visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen…” Review on 3/26/25 of the facility’s undated policy “Plan of Care” revealed, “… The Primary nurse/therapist is responsible for ongoing case management. Revisions to the plan of care are based on on-going assessments and changes in the patient’s condition, with collaboration of the ordering physician and other disciplines…”