Every finding on record at Visiting Nurse & Hospice of Fairfield County Inc

Unannounced visits were concluded at Waveny Home HealthCare on 08/07/2024 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at 484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded on 08/07/2024 at Waveny Home HealthCare for the purpose of a recertification survey. Standard-level deficiencies were identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record reviews, review of an agency policies and interview with agency staff, for two of three patients (Patient #9 in the survey sample who required nursing assessments and weight monitoring and (Patient #13) who required nursing assessments and blood glucose monitoring, the agency’s nurse failed to follow a physician’s orders and/or ensure the plan of care addressed the patient’s individual needs. The findings include: a. Patient #9 had a start of care 05/09/2024 with diagnoses that included chronic congestive heart failure, hemiplegia from a stroke, anemia, and celiac disease. The physician’s orders for the certification period of 07/08/2024 to 09/05/2024 included nursing once per week for eight weeks for nursing assessments. Review of Patient #9’s recertification plan of care and nursing summary dated 07/06/2024, identified the Patient had an unsteady gait and a history of falls. The physician’s recertification orders dated 07/06/2024, identified to teach the patient and caregiver to weigh the patient and weight monitoring due to the diagnosis of congestive heart failure. Review of Patient #9’s nursing notes dated 07/13/2024, 07/17/2024, 07/25/2024, and 08/04/2024, identified the Patient was unable to stand on a scale. i. Interview and review of Patient #9’s clinical record with the Administrator on 08/07/2024 at 10:30 AM, identified Registered Nurse (RN) #1 failed to update the Patient’s plan of care to reflect his/her inability to stand on a scale. b. Patient #13 had a start of care date of 04/05/2024 with diagnoses that included type II diabetes, chronic kidney disease, chronic venous insufficiency, and anemia. The physician’s orders for the certification period of 06/04/2024 to 08/02/2024 included nursing services twice per week for nine weeks for nursing assessments, wound care to the bilateral lower extremities, to provide diabetes management education, and blood glucose monitoring. ii. Interview and review of Patient #13’s clinical record with the Administrator on 08/07/2024 at 10:45 AM, identified the Patient had a glucometer (a device used to measure the amount of glucose/sugar is in a blood sample) in the home, but was non-compliant with using the glucometer. The Administrator further identified Registered Nurse (RN) #1 failed to check the Patient’s blood glucose during nursing visits and failed to update the Patient’s plan of care with physician ordered blood glucose parameters. Review of the agency’s Contents of Clinical Record policy, identified a clinical record would be maintained for each patient receiving care. At all times the clinical record would contain sufficient information that included functional limitations related to care and services provided and description of client’s activity restrictions related to care and services, documentation of the assessment data collected, actions and interventions performed and client response to care provided.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record reviews, interview with agency staff, and review of agency policies, for two of seven patients (Patient's #4 & #10) who required nursing assessments and wound care, the agency nurses failed to perform the necessary assessments in accordance with the agency’s policy. The findings include: a. Patient #10 had a start of care date of 05/28/2024 with diagnosis that included a stage two pressure ulcer to the left buttock, dementia, convulsions, and a history of falls. The physician’s orders for the certification period of 05/28/2024 to 07/26/2024 included nursing services twice per week for nine weeks for nursing assessments and wound care. i. Interview and review of Patient #10’s clinical record with the Administrator on 08/07/2024 at 10:30 AM, identified on 06/08/2024 the Patient had developed a stage one pressure ulceration to the left hip, but failed to identify the new wound was measured. Additionally, the agency’s nurses failed to measure the Patient’s stage two pressure ulceration to the left buttock and stage one pressure to left hip for the week of 06/16/2024. Review of the agency’s Wound Assessment policy, identified during each home visit the wound measurements would be documented at least once per week. Patient #4 had a start of care date of 6/17/24 and diagnoses that included chronic pain syndrome, stage II pressure ulcer of the right upper back, left lower leg laceration and hypertension. Physician's orders dated 6/17/24 included nursing services three times a week for assessments and wound care to the right anterior tibial area, the left anterior tibial area and the right upper back pressure ulcer. Additionally, the patient received home health aide, physical therapy, speech therapy and occupational therapy services. Interview and review of the clinical record with the Administrator on 8/07/24 at 11:35 AM failed to identify weekly wound measurements the weeks of 6/23/24-6/29/24, 6/30/24-7/06/24 and 7/07/24 -7/13/24 of all three wounds. Subsequent to surveyor inquiry, RN #1 incorporated the wound measurements on 8/06/24 from the notepad used during his/her visits on 6/27/24, 7/03/24 and 7/10/24.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record reviews, interview with agency staff, and review of agency policies, for one of three patients (Patient #13) who required nursing assessments and blood glucose monitoring, the agency failed to perform the necessary assessments. The findings include: a. Patient #13 had a start of care date of 04/05/2024 with diagnoses that included type II diabetes, chronic kidney disease, chronic venous insufficiency, and anemia. The physician’s orders for the certification period of 06/04/2024 to 08/02/2024 included nursing services twice per week for nine weeks for nursing assessments, wound care to the bilateral lower extremities, to provide diabetes management education, and blood glucose monitoring. i. Interview and review of Patient #13’s clinical record with the Administrator on 08/07/2024 at 10:45 AM, identified the Patient had a glucometer (a device used to measure the amount of glucose/sugar is in a blood sample) in the home, but was non-compliant with using the glucometer. The Administrator further identified Registered Nurse (RN) #1 failed to check the Patient’s blood glucose during nursing visits and failed to update the Patient’s plan of care with physician ordered blood glucose parameters.

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 review of clinical records, review of an agency policy and interview with agency personnel, for three of thirteen patients (Patient's #4, #8 and #10) in the survey sample who received nursing services, the agency’s nurse failed to ensure clinical records were complete and incorporated into patient records. The findings include: Patient #4 had a start of care date of 6/17/24 and diagnoses that included chronic pain syndrome, stage II pressure ulcer of the right upper back, left lower leg laceration and hypertension. Physician's orders dated 6/17/24 included nursing services three times a week for assessments and wound care to the right anterior tibial area, the left anterior tibial area and the right upper back pressure ulcer. Additionally, the patient received home health aide, physical therapy, speech therapy and occupational therapy services. i. Interview and review of the clinical record with the Administrator on 8/07/24 at 11:30 AM identified RN #1’s nursing notes dated 6/27/24 and 7/01/24 were not submitted until 7/08/24, the nursing note dated 6/29/24 was not submitted until 7/03/24, the nursing note dated 7/03/24, was not submitted until 7/10/24, the nursing note dated 7/05/24, was not submitted until 7/17/24, the nursing note dated 7/10/24 was not submitted until 7/14/24 and LPN #1’s nursing note dated 7/08/24, was not submitted until 7/16/24 and failed to ensure nursing notes were completed on the date services were rendered and incorporated into the patients’ clinical records within twenty- four hours after the visit in accordance with the agency’s policy. ii. Interview and review of the clinical record with the Administrator on 8/07/24 at 11:35 AM failed to identify weekly wound measurements the weeks of 6/23/24-6/29/24, 6/30/24-7/06/24 and 7/07/24 -7/13/24 of all three wounds. Subsequent to surveyor inquiry, RN #1 incorporated the wound measurements on 8/06/24 from the notepad used during his/her visits on 6/27/24, 7/03/24 and 7/10/24 and failed to ensure all clinical notes were incorporated timely. a. Patient #8 had a start of care date of 06/02/2024 with diagnosis that included a stage two pressure ulcer to the left ankle, a stage one pressure ulcer to the sacral area, dementia, chronic kidney disease and anemia. The physician’s orders for the certification period of 06/02/2024 to 07/31/2024 included nursing services twice per week for nine weeks for nursing assessments and wound care and physical therapy twice per week. b. Patient #10 had a start of care date of 05/28/2024 with diagnosis that included a stage two pressure ulcer to the left buttock, dementia, convulsions, and a history of falls. The physician’s orders for the certification period of 05/28/2024 to 07/26/2024 included nursing services twice per week for nine weeks for nursing assessments and wound care. i. Interview and review of Patient #8 and #10’s clinical records with the Administrator on 08/07/2024 at 11:45 AM, identified Patient #8’s nursing note dated 06/09/2024 was not submitted until 07/09/2024, nursing notes dated 06/12/2024 and 06/20/2024 were not submitted until 06/30/2024, a nursing note dated 06/27/2024 was not submitted until 07/10/2024, and nursing notes dated 07/01/2024, 07/06/2024, 07/09/2024 were not submitted until 07/19/2024. Additionally, Patient #10’s nursing note dated 06/11/2024 was not submitted until 06/17/2024, a nursing note dated 06/17/2024 was not submitted until 06/26/2024 and a nursing note dated 06/21/2024 was not submitted until 06/29/2024. The Administrator identified Registered Nurse (RN) #1 failed to ensure nursing notes were completed on the date services were rendered and incorporated into the patients’ clinical records within twenty- four hours after the visit in accordance with the agency’s policy and expectation. Review of the agency’s Competency Based Orientation policy identified all documentation must be completed within twenty-four hours and incorporated into the patient’s clinical record.