Every finding on record at VNA & Hospice of Cooley Dickinson

A Recertification survey was conducted at VNA & Hospice of Cooley Dickinson, located at 30 Locust Street, Northampton, MA., 01060, on April 22, 2026, April 23, 2026, April 24, 2026, and April 28, 2026, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at VNA & Hospice of Cooley Dickinson, located at 30 Locust Street, Northampton, MA., 01060, on April 22, 2026, April 23, 2026, April 24, 2026, and April 28, 2026, to determine compliance with the 42 CFR Part 484 Requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

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 observation, policy review, and interview, the agency failed to ensure infection control guidelines were maintained during an observation of a wound dressing change for 1 patient (#7), out of a total of 7 patient home visits. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Core Infection and Control Practices for Safe Healthcare Delivery in All Settings, dated 4/12/24, indicated the following: -Clean and reprocess (disinfect or sterilize) reusable medical equipment prior to use on another patient or when soiled. Patient #7 was admitted to the agency in February 2026 with a diagnosis of Type 2 Diabetes Mellitus (DM-a chronic condition characterized by high blood sugar and insulin resistance) with foot ulcer (an open sore). Review of the physician ordered Home Health Plan of Care for certification period 4/9/26 through 6/7/2026 indicated the following: -Wound care to left plantar section (bottom surface) of foot, remove dressing, wash with normal saline, apply Triad (brand name) wound cream to open area followed by dry clean dressing, gauze, and secure with tape. During a home visit on 4/24/26 at 10:00 A.M., the surveyor observed Registered Nurse (RN) place wound dressing supplies, including bandage scissors, on a barrier pad prior to beginning a dressing change to Patient #7 left foot. She cleansed her hands and donned (put on) gloves. She took the bandage scissors into her gloves hands and cut across the gauze on Patient #7 left foot to loosen it off and removed the dressing. She doffed (removed ) her gloves, cleansed her hands, donned new gloves and completed the dressing change. While putting away the extra dressing supplies into a cardboard box, she included the scissors. She did not cleanse the scissors prior to or after the dressing change. During an interview on 4/24/26 at 10:30 A.M., the RN said she did not cleanse the scissors prior to and after use during the wound dressing change, as required

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to ensure a registered nurse (RN) provided supervision of the care provided by a licensed practical nurse (LPN) every 30 days for 4 patients (#3, #4, #7 and #8), out of a total sample of 17 patient records reviewed. Findings include: Review of the agency policy entitled, Supervision, dated 11/10/25, included the following: -LPN Supervision: The Agency identifies an RN to supervise the care provided by an LPN. The RN monitors and evaluates the LPN performance in the provision of services, provision of treatments, patient education, communication with the RN, and data collection regarding the patient's status and health needs as delegated by the RN. Only the RN may perform comprehensive assessment, evaluation, care plan modifications, and discharge assessment. The RN will see the patient every 30 days to perform this supervision. 1. Patient #3 was admitted to the agency in March 2026 with a diagnosis of hemiplegia (paralysis causing partial or total loss of movement on one side of the body) and hemiparesis (partial weakness or reduced motor control affecting one side of the body) following cerebral infarction (a stroke) affecting right dominant side. Review of the physician ordered Home Health Plan of Care (POC) for certification period 3/25/26 through 5/23/26 indicated the following: *Skilled Nurse (SN) visits: 2 visits every week for 1 week from 3/25/26 to 3/28/26, 1 visit every week for 8 weeks from 3/29/26 to 5/23/26, and 3 visits as needed. Review of the clinical record indicated LPN visits were provided on 3/27/26, 4/8/26, 4/10/26, 4/14/26, 4/16/26, and 4/21/26. Further review of the clinical record did not contain any documentation that LPN supervisory visits were completed by an RN, as required. 2. Patient #4 was admitted to the agency in March 2026 with a diagnosis of myocardial infarction (heart attack). Review of the physician ordered Home Health POC for certification period 3/17/26 through 5/15/26 indicated the following: *SN visits: 2 visits every week for 1 week from 3/17/2 to 3/21/236, 1 visit every week for 8 weeks from 3/22/26 to 5/15/26, and 3 visits as needed. Review of the clinical record indicated LPN visits were provided on 3/20/26, 4/14/26 and 4/23/26. Further review of the clinical record did not contain any documentation that LPN supervisory visits were completed by an RN, as required. 3. Patient #7 was admitted to the agency in February 2026 with a diagnosis of Type 2 Diabetes Mellitus (DM-a chronic condition characterized by high blood sugar and insulin resistance) with foot ulcer (an open sore). Review of the physician ordered Home Health POC for certification period 2/8/26 through 4/8/26 indicated the following: *SN visits: 2 visits every week for 4 weeks from 2/8/26 to 3/7/26, and 1 visit every week for 5 weeks from 3/8/26 to 4/8/26. Review of the physician ordered Home Health POC for certification period 4/9/26 through 6/7/26 indicated the following: *SN visits: 1 time a week for 1 week from 4/9/26 to 4/11/26, 3 visits every week for 8 weeks from 4/12/26 to 6/6/26, and 3 visits as needed. Review of the clinical record indicated LPN visits were provided on 3/2/26, 3/8/26, 3/24/26, 4/15/26, 4/17/26, and 4/20/26. Further review of the clinical record did not contain any documentation that LPN supervisory visits were completed by an RN, as required. 4. Patient #8 was admitted to the agency in March 2026 with a diagnosis of surgical aftercare following surgery on the circulatory (cardiovascular) system. Review of the physician ordered Home Health POC for certification period 3/23/26 through 5/21/26 indicated the following: *SN visits: 2 visits every week for 4 weeks from 3/23/26 to 4/18/26, 1 visit every week for 5 weeks from 4/19/26 through 5/21/26, and 3 visits as needed. Review of the clinical record indicated LPN visits were provided on 3/31/26, 4/2/26, 4/9/26, 4/14/26, 4/16/26, and 4/22/26. Further review of the clinical record did not contain any documentation that LPN supervisory visits were completed by an RN, as required. During an interview on 4/28/26 at 3:30 P.M., the Administrative Director said there was no documentation in the clinical records for Patients #3, #4, #7 and #8 to indicate that LPN supervisory visits had been completed every 30 days, as required.

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 record review, policy review, and interview, the agency failed to ensure clinical documentation was complete and appropriately authenticated and dated in accordance with currently accepted standards of practice for 7 patients (#2, #3, #6, #7, #9, #13 and #14), out of a total sample of 17 patients. Findings include: Review of the agency policy entitled, Documentation, dated 6/23/25, included the following: -All documentation in the patient medical record must be completed in a thorough, timely manner for safe hand off to the next provided of care. -All documentation must be completed according to the following guidelines: *Routine Visit, encounter to be closed in 1 calendar day. *Start of Care (SOC) OASIS Assessment (a group of standard data elements developed to enable systemic comparative measurements of home health care patient outcomes) encounter to be closed within 2 calendar days of SOC date. 1. Patient #2 was admitted to the agency in March 2026 with a diagnosis of displaced bimalleolar fracture of right lower leg (inner and outer bones of the ankle are broken). Review of the physician ordered Home Health Plan of Care (POC) for certification period 3/3/26 through 5/1/26 indicated the following: -Occupational Therapy (OT) visits: 1 visit every week for 1 week from 3/5/26 through 3/7/26. Review of the clinical record contained the following: *3/31/26 OT Cancelled visit, note was signed on 4/17/26. 2. Patient #3 was admitted to the agency in March 2026 with a diagnosis of hemiplegia (paralysis causing partial or total loss of movement on one side of the body) and hemiparesis (partial weakness or reduced motor control affecting one side of the body) following cerebral infarction (a stroke) affecting right dominant side. Review of the physician ordered Home Health POC for certification period 3/25/26 through 5/23/26 indicated the following: -Home Health Aide (HHA) visits: 2 visits every week for 8 weeks from 3/29/26 through 5/23/26. Review of the clinical record contained the following: *4/14/26 HHA visit, note was signed on 4/16/26. 3. Patient #6 was admitted to the agency in March 2026 with a diagnosis of displaced supracondylar fracture of lower end of left femur (a break in the thigh bone just above the knee joint). Review of the clinical record contained OASIS SOC Visit, dated 3/12/26, that was signed on 3/15/26. 4. Patient #7 was admitted to the agency in February 2026 with a diagnosis of Type 2 Diabetes Mellitus (DM-a chronic condition characterized by high blood sugar and insulin resistance) with foot ulcer (an open sore). Review of the physician ordered Home Health POC for certification period 2/8/26 through 4/8/2026 indicated the following: -Skilled Nurse (SN) visits: 2 visits every week for 4 weeks from 2/8/26 to 3/7/26, 1 visit every week for 5 weeks from 3/8/26 to 4/8/26, and 3 visits as needed. -OT visits: 2 visits every week for 1 week from 2/10/26 to 2/14/26, 1 visit every week for 1 week from 2/15/26 to 2/21/26, and 2 visits every week for 2 weeks from 2/22/26 to 3/7/26. -Speech Language Pathology (SLP) visits: 1 visit every 2 weeks for 2 weeks from 2/8/26 to 2/21/26. Review of the clinical record contained the following: *2/26/216 SN visit, note was signed on 3/1/26. *3/2/26 Licensed Practical Nurse (LPN) visit, note was signed on 3/4/26. *3/5/25 OT Therapy Functional Assessment (TFA) visit, note was signed on 3/10/26. *4/5/26 SLP visit, note was signed on 4/10/26. 5. Patient #9 was admitted to the agency with a diagnosis of malignant neoplasm (abnormal growth) of the hypopharynx (lowest part of the throat). Review of the physician ordered Home Health POC for certification period 3/13/26 through 5/11/26 indicated the following: -SN visits: effective 3/15/26, 2 visits every week for 6 weeks from 3/15/26 to 4/25/26, and 3 visits as needed. Review of the clinical record contained the following: *4/13/26 SN Cancelled visit, note was signed on 4/22/26. 6. Patient #13 was admitted to the agency in November 2025 with a diagnosis of osteoporosis with fracture of right femur. Review of the physician ordered Home Health POC for certification period 1/2/26 through 3/2/26 indicated the following: -SN visits: 1 visit every week for 9 weeks from 1/2/26 to 2/28/26. Review of the clinical record indicated the following: *1/2/26 SN visit, note was signed on 1/5/26. *1/9/26 SN visit, note was signed on 1/12/26. *1/16/26 SN Cancelled Visit, note was signed on 1/21/26. 7. Patient #14 was admitted to the agency in January 2026 with a diagnosis of multiple right rib fractures. Review of the physician ordered Home Health POC for certification period 3/10/26 through 5/8/26 indicated the following: -Physical Therapy (PT) visits: 1 visit every week for 3 weeks from 3/10/26 to 3/28/26. Review of the clinical record indicated the following: *3/26/26 PT visit, note was signed on 3/29/26. During an interview on 4/28/26 at 3:30 P.M., after reviewing the visit notes for Patients #2, #3, #6, #7, #9, #13 and #14, the Administrative Director said the notes were signed late and not within the required timeframe.

A Recertification survey was conducted at Visiting Nurses Association (VNA) and Hospice of Cooley Dickinson on 5/17/23 through 5/19/23 and 5/23/23, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the Agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at Visiting Nurses Association (VNA) and Hospice of Cooley Dickinson on 5/17/23 through 5/19/23 and on 5/23/23, to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the Agency was not in compliance with these requirements. Deficiencies were cited.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff conformed with the Physician orders for two Patients (#2 and #17), out of a total sample of 17 Patients. Specifically, a) For Patient #2, Home Health Aide visits (HHAVs) were not provided, as ordered, and b) For Patient #17, Physical Therapy visits (PTVs) were not provided, as ordered. Findings include: Review of the Agency's policy, Establishment and Revision of Visiting Nurses Association (VNA) Plan of Care, dated April 2018, included, but not limited to, the following: -The plan of care establishes and maintains an individualized plan for each patient admitted to the VNA. -The plan of care is developed and implemented based on a comprehensive needs assessment that is completed by the designated clinical discipline. The plan is developed in collaboration with the Patient and the Patient's Physician and is signed by the Physician. 1. Patient #2 was admitted to the Agency in October 2022 with a diagnosis of Amyotrophic Lateral Sclerosis (ALS - a nervous system disease that weakens muscles and impacts physical function). Review of the Physician's orders for certification period 2/22/23 through 4/22/23, indicated the following: -Effective 3/20/23 to 3/25/23, HHAV once a week for one week. -Effective 3/26/23 to 4/22/23, HHAVs twice a week for four weeks. Review of the clinical record indicated no HHAV was provided, as ordered, from 3/20/23 to 3/25/23. Further review of the record indicated a HHAV was refused by Patient #2 on 3/27/23, and a second visit was not provided, as ordered, during the week of 3/26/23 to 4/1/23. During an interview on 5/23/23 at 3:40 P.M., after reviewing the clinical record, the Quality Director said the Physician's order for HHAVs as indicated in the plan of care, were not followed. 2. Patient #17 was admitted to the Agency in March 2023 with a diagnosis of Alcoholic Cirrhosis (chronic liver damage leading to scarring and liver failure) with Ascites (excess abdominal fluid). Review of the Physician's orders for certification period 3/5/23 through 5/3/23, indicated the following: -Effective 3/22/23, PTV twice a week for five weeks. Review of two missed PTV notes, dated 3/27/23 and 3/29/23, indicated that PTVs were not provided, as ordered, due to Clinician's illness. Further review of the record indicated the Agency did not attempt to provide an alternate Physical Therapist (PT) or Physical Therapist Assistant (PTA) to provide the two PTVs, as ordered, during the week of 3/26/23 to 4/1/23. During an interview on 5/23/23 at 8:30 A.M., after reviewing the clinical record, the Quality Director said the Agency should have contacted Patient #17 and attempted to have another PT or PTA provide PTVs, as ordered, if he/she was receptive. She said there was no documentation that this was offered. She said the Physician's order for PTVs as indicated in the plan of care, were not followed during the week of 3/26/23 to 4/1/23.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff signed clinical notes within 24 hours after providing a home visit for 13 Patients (#1, #4, #11, #12, #13, #14, #15, #2, #3, #5, #9, #16 and #17), out of a total sample of 17 Patients. Findings include: Review of the Agency policy titled, Documentation Policy, revised 1/10/2018, included, but not limited to: -All documentation in the patient medical record must be completed in a thorough, timely manner for safe hand off to the next provider. -All documentation must be completed according to the following guidelines: a. Routine Visit, the Encounter should be closed within one calendar day. b. Medication Reconciliation (Must document communication with the Physician), the Encounter should be closed within one calendar day. c. Physician Orders for additions or changes to medications, the Encounter should be closed the business day on the day the order is received. d. Physician Orders for changes to interventions, the Encounter should be closed the business day on the day the order is received. e. Plan of Care, the Encounter should be closed within one calendar day. f. Start of Care (SOC), the Outcome and Assessment Information Set (OASIS), the Encounter should be closed within two calendar days of the SOC date. g. Resumption of Care (ROC), the Encounter should be closed within two days of the ROC. h. Transfer to an inpatient facility, with or without discharge from the Agency, the Encounter should be closed within two calendar days of knowledge of the transfer or discharge. i. Recertification, the Encounter should be closed within two days of the recertification date. j. Significant change in the patient condition, the Encounter should be closed on the business day on the day the change is identified. k. Discharge-the Encounter should be closed within two calendar days of knowledge of the discharge or death. 1. Patient #1 was admitted to the Agency in April 2023 with a diagnosis of Encounter for Surgical Aftercare Following Surgery on the Circulatory System (the system that contains the heart and the blood vessels and moves blood throughout the body. Review of the Physician orders for certification period 4/17/23 through 6/15/23 included, but not limited to: -Physical Therapy Visit (PTV), effective 5/1/23 to 5/27/23, twice a week for four weeks. Review of the clinical record indicated a PTV occurred on 5/1/23, and the clinical note was signd closed on 5/4/23. 2. Patient #4 was admitted to the Agency in March 2023 with a diagnosis of Malignant Neoplasm (Cancer) of Bilateral Ovaries. Review of the Physician orders for certification period 3/29/23 through 5/27/23 indicated the following: -Skilled Nurse Visit (SNV), effective 3/29/23 to 4/1/23, one visit for one week. -SNV, effective 3/29/23 to 5/27/23, three visits, as needed (PRN). -SNV, effective 4/2/23 to 4/8/23, two visits a week for one week. -SNV, effective 4/9/23 to 5/27/23, one visit a week for seven weeks. -PTV, effective 4/10/23 to 5/13/23, twice a week for five weeks. -Home Health Aide Visit (HHAV), effective 4/2/23 to 5/27/23, two visits a week for eight weeks. Review of the clinical record indicated the following: -PTV occurred on 4/10/23 and, and the the clinical note was closed on 4/17/23. -PTV was canceled on 4/14/23 and the clinical note was signed and closed on 4/16/23. -HHAV occurred on 4/20/23, and the clinical note was signed and closed on 4/22/23. -PTV was cancelled on 4/24/23, and the clinical note was signed and closed on 4/30/22. -HHAV occurred on 4/25/23, and the clinical note was signed and closed on 4/27/23. -Licensed Practical Nurse Visit (LPNV) occurred on 4/27/23, and the clinical note was signed and closed on 5/4/23. -PTV occurred on 4/27/23, and the clinical note was signed and closed on 4/30/23. -PTV occurred on 5/1/23, and the clinical note was signed and closed on 5/4/23. -HHAV occurred on 5/8/23, and the clinical note was signed and closed on 5/10/23. 3. Patient #11 was admitted to the Agency in April 2023 with a diagnosis of Fracture of the left Femur Neck (hip fracture of the thigh bone). Review of the Physician orders for the certification period 4/22/23 through 6/20/23 included, but not limited to: -HHAV, effective 4/23/23 to 6/17/23, two visits a week for eight weeks. -SNV, effective 4/22/23 to 4/22/23, one visit for one week. -SNV, effective 4/22/23 to 6/20/23, three PRN visits. -SNV, effective 4/23/23 to 4/29/23, three visits for one week. -SNV, effective 4/30/23 to 6/20/23, one visit a week for eight weeks. Review of the clinical record indicated the following: -HHAV occurred 4/26/23, and the clinical note was signed and closed 4/30/23. -HHAV occurred on 4/27/23, and the clinical note was signed and closed on 4/30/23. -SNV occurred on 4/28/23, and the clinical note was signed and closed on 4/30/23. -HHAV occurred on 5/3/23, and the clinical note was signed and closed on 5/5/23. -HHAV occurred on 5/5/23, and the clinical note was signed and closed on 5/7/23. -HHAV occurred on 5/12/23, and the clinical note was signed and closed on 5/14/23. 4. Patient #12 was admitted to the Agency in April 2023 with a diagnosis of Hereditary Motor and Sensory Neuropathy (a group of hereditary disorders that damage the nerves in the arms and legs). Review of the Physician orders for certification period 4/24/23 through 6/22/23 indicated the following: -SNV, effective 4/24/23 to 4/29/23, two visits for one week. -SNV, effective 4/24/23 to 6/22/23, three PRN visits. -SNV, effective 4/30/23 to 6/22/23, one visit once a week for eight weeks. -PTV, effective 5/4/23 to 5/6/23, one visit for one week. -PTV, effective 5/7/23 to 5/20/23, three visits a week for two weeks. -PTV, effective 5/21/23 to 6/4/23, two visits a week for two weeks. Review of the clinical record indicated the following: -SNV occurred on 4/28/23, and the clinical note was signed and closed on 4/30/23. -SNV occurred on 5/2/23, and the clinical note was signed and closed on 5/8/23. -PTV occurred on 5/4/23, and the clinical note was signed and closed on 5/9/23. -PTV occurred on 5/8/23, and the clinical note was signed and closed on 5/11/23. -LPNV occurred on 5/11/23, and the clinical note was signed and closed on 5/13/23. -PTV occurred on 5/12/23, and the clinical note was signed and closed on 5/17/23. -PTV occurred on 5/15/23, and the clinical note was signed and closed on 5/17/23. 5. Patient #13 was admitted to the Agency in December 2022 with a diagnosis of Focal Partial Idiopathic Epilepsy (seizures that originate in a single brain area). Review of the Physician orders for certification period 12/27/22 through 2/24/23 indicated the following: -SNV, effective 12/27/22 to 1/7/23, two visits a week for two weeks. -SNV, effective 1/8/23 to 2/24/23, one visit a week for seven weeks. -PTV, effective 1/6/23 to 1/7/23, one visit for one week. -PTV, effective 1/8/23 to 2/4/23, two visits a week for four weeks. Review of the clinical record indicated a PTV occurred on 1/6/23, and the clinical note was signed and closed on 1/9/23. Further review indicated a SNV was cancelled on 1/20/23, and the clinical note was signed and closed on 1/23/23. 6. Patient #14 was admitted to the Agency in December 2022 with a diagnosis of Aftercare Following Joint Replacement Surgery. Review of the Physician orders for certification period 12/17/22 through 2/14/23 indicated the following: -PTV, once a week for one week, followed by four times a week for one week, then two times a week for one week. Review of the clinical record indicated a PTV occurred on 1/5/23, and the clinical note was signed and closed on 1/7/23. 7. Patient #15 was admitted to the Agency in January 2023 with a diagnosis of Paroxysmal Atrial Fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of the Physician orders for certification period 1/4/23 through 3/1/23 indicated the following: indicated the following: -PTV, effective 1/7/23 to 1/7/23, one visit for one week. -PTV, effective 1/8/23 to 1/28/23, two visits a week for three weeks. -PTV, effective 1/29/23 to 2/11/23, once a week for two weeks. -Speech Therapy Visit (STV), effective 1/9/23 to 2/4/23, once a week for four weeks. -Occupational Therapy Visit (OTV), effective 1/7/23 to 1/21/23, one visit for one week. Review of the clinical record indicated the following: -PTV occurred on 1/9/23, and the clinical note was signed and closed on 1/12/23. -STV occurred on 1/12/23, and the clinical note was signed and closed on 1/17/23. -PTV occurred on 1/17/23, and the clinical note was signed and closed on 1/31/23. -OTV occurred on 1/17/23, and the clinical note was signed and closed on 1/19/23. -PTV occurred on 1/19/23, and the clinical note was signed and closed on 1/31/23. -PTV occurred on 1/23/23, and the clinical note was signed and closed on 2/9/23. -STV occurred on 1/24/23, and the clinical note was signed and closed on 1/3023. -PTV occurred on 1/26/23, and the clinical note was signed and closed on 2/9/23. -PTV occurred on 1/30/23, and the clinical note was signed and closed on 2/9/23. -PTV occurred on 2/2/23, and the clinical note was signed and closed on 2/9/23. -PTV occurred on 2/6/23, and the clinical note was signed and closed on 3/8/23. -PTV occurred on 2/10/23, and the clinical note was signed and closed on 3/8/23. -PTV occurred on 2/14/23, and the clinical note was signed and closed on 3/8/23. -PTV occurred on 2/21/23, and the clinical note was signed and closed on 3/8/23. -PTV occurred on 2/24/23, and the clinical note was signed and closed on 3/8/23. -PTV occurred on 2/27/23, and the clinical note was signed and closed on 3/8/23. -PTV occurred on 3/1/23, and the clinical note was signed and closed on 3/8/23. During an interview on 5/23/23 at 2:35 P.M., after reviewing the clinical records for Patients #1, #4, #11, #12, #13, #14 and #15, the Quality Nurse said the documented notes were late, and not done within the required 24 hours of the visit. 8. Patient #2 was admitted to the Agency in October 2022 with a diagnosis of Amyotrophic Lateral Sclerosis (ALS (a nervous system disease that weakens muscles and impacts physical function)). a.) Review of the Physician orders for certification period 12/24/22 through 2/21/23, indicated the following: -One PRN SNV. -Effective 12/25/22, one SNV a week for nine weeks. -Effective 12/25/22, one PTV a week for eight weeks. Review of the clinical record indicated the following: -A SNV occurred on 12/27/22, and the clinical note was signed and closed on 12/30/22. -A PTV occurred on 1/27/23, and the clinical note was signed and closed on 1/29/23. -A SNV occurred on 1/31/23, and the clinical note was signed and closed on 2/3/23. -A PTV occurred on 1/27/23, and the clinical note was signed and closed on 1/29/23. -A SNV was cancelled on 2/10/23, and the clinical note was signed and closed on 2/13/23. -A PTV occurred on 2/17/23, and the clinical note was signed and closed on 2/22/23. b.) Review of the Physician orders for certification period 2/22/23 through 4/22/23, indicated the following: -Effective 2/26/23, one PTV a week for eight weeks. -Effective 3/20/23 to 4/15/23, one OTV every four weeks for four weeks (then discontinued on 4/7/23). -Effective 3/26/23 to 4/22/23, one OTV every four weeks for four weeks (then discontinued on 4/7/23). -Effective 4/9/23 to 4/22/23, one OTV every week for two weeks. Review of the clinical record indicated the following: -A PTV occurred on 3/3/23, and the clinical note was signed and closed on 3/5/23. -An OTV was cancelled on 3/28/23, and the clinical note was signed and closed on 3/30/23. -A PTV occurred on 3/31/23, and the clinical note was signed and closed on 4/3/23. -An OTV (evaluation) occurred on 4/5/23, and the clinical note was signed and closed on 4/12/23. -An OTV occurred on 4/14/23, and the clinical note was signed and closed on 4/18/23. -An OTV was cancelled on 4/21/23, and the clinical note was signed and closed on 4/24/23. -A PTV occurred on 4/21/23, and the clinical note was signed and closed on 4/25/23. c.) Review of the Physician's orders for certification period 4/23/23 through 6/21/23, indicated the following: -A PTV once a week for eight weeks. -Effective 4/23/23 to 4/29/23, one OTV. -Effective 5/1/23 to 5/6/23, one OTV. -Effective 5/14/23 to 5/20/23, one OTV. Review of the clinical record indicated the following: -An OTV was cancelled 4/28/23, and the clinical note was signed and closed 5/1/23. -A PTV occurred on 4/28/23, and the clinical note was signed and closed on 5/1/23. -An OTV occurred on 5/2/23, and the clinical note was signed and closed on 5/5/23. -A PTV occurred on 5/12/23, and the clinical note was signed and closed on 5/14/23. 9. Patient #3 was admitted to the Agency in April 2023 with a diagnosis of Cognitive (memory) Issues Related to a Nontraumatic Intracerebral Hemorrhage (stroke, bleeding into the substance of the brain in the absence of trauma or surgery). Review of the Physician orders for certification period 4/10/23 through 6/8/23, indicated the following: -Three PRN SNVs. -Effective 4/10/23 to 4/15/23, SNV once a week for one week. -Effective 4/16/23, SNV once a week for eight weeks. -Effective 4/12/23 to 4/15/23, OTV once a week for one week. -Effective 4/16/23 to 4/22/23, OTV twice a week for one week. -Effective 4/23/23 to 5/20/23, OTV once a week for four weeks. -Effective 4/12/23 to 5/6/23, PTV twice a week for two weeks. -Effective 57/23 to 6/3/23, PTV once a week for four weeks. -Effective 4/23/23 to 4/29/23, STV once a week for one week. -Effective 4/30/23 to 5/27/23, STV twice a week for four weeks. Review of the clinical record indicated the following: -An OTV occurred on 4/12/23, and the clinical note was signed and closed on 4/24/23. -A PTV occurred on 4/12/23, and the clinical note was signed and closed on 4/16/23. -An OTV occurred on 4/18/23, and the clinical note was signed and closed on 4/24/23. -An OTV was cancelled on 4/19/23, and the clinical note was signed and closed on 4/24/23. -A PTV occurred on 4/21/23, and the clinical note was signed and closed on 4/24/23. -A SNV was cancelled on 4/21/23, and the clinical note was signed and closed on 4/24/23. -A PTV occurred on 4/25/23, and the clinical note was signed and closed on 4/30/23. -A STV occurred on 4/26/23, and the clinical note was signed and closed on 5/2/23. -A SNV occurred on 4/26/23, and the clinical note was signed and closed on 4/30/23. -A PTV occurred on 4/28/23, and the clinical note was signed and closed on 5/1/23. -A PTV occurred on 5/3/23, and the clinical note was signed and closed on 5/8/23. -A STV occurred on 5/4/23, and the clinical note was signed and closed on 5/8/23. 10. Patient #5 was admitted to the Agency in February 2023 with a diagnosis of Left Femur Fracture. a.) Review of the Physician orders for certification period 2/18/23 to 4/18/23, indicated the following: -Three PRN SNVs. -Effective 2/18/23, one SNV for one day. -Effective 2/19/23 to 2/25/23, SNV twice a week for one week. -Effective 2/26/23, SNV once a week for eight weeks. -Effective 2/21/23 to 3/18/23, PTV twice a week for four weeks, -Effective 3/19/23 to 4/1/23, PTV three times a week for two weeks. -Effective 4/4/23 to 4/15/23, PTV twice a week for two weeks, -Effective 4/16/23 to 4/18/23, PTV once a week for one week. -Effective 4/2/23 to 4/15/23, STV once every two weeks for two weeks. -Effective 4/9/23 to 4/18/23, STV twice a week for two weeks. Review of the clinical record indicated the following: -A PTV occurred on 2/21/23, and the clinical note was signed and closed on 3/7/23. -A SNV occurred on 2/22/23, and the clinical note was signed and closed on 2/27/23. -A PTV occurred on 2/24/23, and the clinical note was signed and closed on 3/8/23. -A PTV occurred on 2/27/23, and the clinical note was signed and closed on 3/8/23. -A PTV occurred on 3/1/23, and the clinical note was signed and closed on 3/8/23. -A SNV occurred on 3/7/23, and the clinical note was signed and closed on 3/9/23. -A PTV occurred on 3/17/23, and the clinical note was signed and closed on 3/30/23. -A SNV occurred on 3/21/23, and the clinical note was signed and closed on 3/27/23. -A PTV occurred on 3/23/23, and the clinical note was signed and closed on 3/28/23. -A PTV occurred on 3/24/23, and the clinical note was signed and closed on 3/28/23. -A PTV occurred on 3/27/23, and the clinical note was signed and closed on 4/10/23. -A PTV occurred on 3/29/23, and the clinical note was signed and closed on 4/10/23. -A PTV occurred on 3/31/23, and the clinical note was signed and closed on 4/10/23. -A PTV occurred on 4/5/23, and the clinical note was signed and closed on 4/11/23. -A PTV occurred on 4/7/23, and the clinical note was signed and closed on 4/17/23. -A STV occurred on 4/11/23, and the clinical note was signed and closed on 4/18/23. -A PTV occurred on 4/11/23, and the clinical note was signed and closed on 4/20/23. -A STV occurred on 4/12/23, and the clinical note was signed and closed on 4/18/23. -A PTV occurred on 4/14/23, and the clinical note was signed and closed on 4/20/23. -A STV occurred on 4/18/23, and the clinical note was signed and closed on 4/20/23. -A PTV occurred on 4/18/23, and the clinical note was signed and closed on 4/21/23. b.) Review of the Physician orders for certification period 4/19/23 to 6/17/23, indicated the following: -Effective 4/19/23 to 4/22/23, STV once a week for one week. -Effective 4/23/23 to 5/6/23, STV twice a week for two weeks. -Effective 5/7/23 to 6/17/23, STV once a week for six weeks. -Effective 4/19/23 to 4/22/23, PTV once a week for one week. -Effective 4/23/23 to 5/20/23, PTV twice a week for four weeks. -Effective 5/23/23 to 6/10/23, PTV twice a week for three weeks. Review of the clinical record indicated the following: -A STV occurred on 4/19/23, and the clinical note was signed and closed on 4/23/23. -A PTV occurred on 4/21/23, and the clinical note was signed and closed on 4/26/23. -A PTV occurred on 4/25/23, and the clinical note was signed and closed on 4/27/23. -A PTV occurred on 4/26/23, and the clinical note was signed and closed on 5/1/23. -A PTV occurred on 4/28/23, and the clinical note was signed and closed on 5/1/23. -A PTV occurred on 5/2/23, and the clinical note was signed and closed on 5/5/23. -A PTV occurred on 5/3/23, and the clinical note was signed and closed on 5/9/23. -A PTV occurred on 5/5/23, and the clinical note was signed and closed on 5/9/23. -A PTV occurred on 5/10/23, and the clinical note was signed and closed on 5/18/23. -A PTV occurred on 5/12/23, and the clinical note was signed and closed on 5/18/23. -A PTV occurred on 5/16/23, and the clinical note was signed and closed on 5/18/23. 11. Patient #9 was admitted to the Agency in April 2023 with a Displaced Bicondylar Fracture of the Left Tibia (bone break of both condyles (end of the bones)). Review of the Physician orders for certification period 4/29/23 through 6/27/23, indicated the following: -Effective 4/29/23, one PTV. -Effective 4/30/23, PTV twice a week for four weeks. -Effective 5/7/23 to 5/20/23, PTV three times a week for 2 weeks. Review of the clinical record indicated the following: -A PTV occurred on 5/9/23, and the clinical note was signed and closed on 5/12/23. -A PTV occurred on 5/11/23, and the clinical note was signed and closed on 5/16/23. 12. Patient # 16 was admitted to the Agency in March 2023 with a diagnosis of Diabetes Mellitus (refers to a group of disease that affect how the body uses blood sugars) with a Foot Ulcer (open sores or lesions that will not heal or return over a long period of time). Review of the Physician orders for certification period 3/13/23 through 5/13/23, indicated the following: -Five PRN SNVs. -Effective 3/16/23 to 4/1/23, SNV twice a week for three weeks. -Effective 4/2/23 to 5/13/23, SNV once a week for 6 weeks. Review of the clinical record indicated the following: -A SNV occurred on 3/16/23, and the clinical note was signed and closed on 3/22/23. -A SNV occurred on 3/20/23, and the clinical note was signed and closed on 3/30/23. -A SNV was cancelled on 3/31/23, and the clinical note was signed and closed on 4/2/23. -A SNV occurred on 5/1/23, and the clinical note was signed and closed on 5/3/23. 13. Patient #17 was admitted to the Agency in March 2023 with a diagnosis of Alcoholic Cirrhosis (chronic liver damage leading to scarring and liver failure) with Ascites (excess abdominal fluid). Review of the Physician orders for certification period 3/5/23 through 5/3/23, indicated the following: -Effective 3/13/23, OTV twice a week for two weeks. -Effective 3/26/23, OTV twice a week for one week. Review of the clinical record indicated an OTV occurred on 3/30/23, and the clinical note was signed and closed on 4/7/23. During an interview on 5/23/23 at 8:30 A.M., and again at 3:45 P.M., after reviewing the clinical records of Patient #2, #3, #5, #9, #16 and #17, the Quality Director said documented notes were signed and closed later than required, per the policy.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure its staff communicated with the Physician when there was a change to the plan of care for two Patients (#2 and #13), out of a total sample of 17 Patients. Specifically, 1) For Patient #2, agency staff did not notify the Physician when Home Health Aide visits (HHAVs) and Skilled Nursing visits (SNVs) were not provided as ordered, and 2) For Patient #17, the agency staff failed to notify the Physician when the Patient was discharged from the Agency, before the end of the Physician ordered certification period. Findings Include: Review of the Agency's policy, Establishment and Revision of Visiting Nurses Association (VNA) Plan of Care, dated April 2018, included, but not limited to, the following: -The Physician should be promptly alerted to any time during the Patient's home care episode, if there are any changes in the Patient's physical or psychosocial condition that suggest a need to alter the plan of care. This action will be documented in the Patient's medical record and an interim order will be sent for a Physician signature or notification as required. Patient #2 was admitted to the Agency in October 2022 with a diagnosis of Amyotrophic Lateral Sclerosis (ALS (a nervous system disease that weakens muscles and impacts physical function)). a.) Review of the Physician orders for certification period 12/24/22 through 2/21/23, indicated the following: -One As Needed (PRN) SNV. -Effective 12/25/22, SNV once a week for nine weeks. Review of the clinical record indicated a missed SNV note, dated 1/24/23. The note did not indicate the Physician was notified of the missed SNV. b.) Review of a Physician orders for certification period 2/22/23 to 4/22/23, indicated the following: -One PRN SNV. -Effective 2/28/23 to 3/4/23, SNV once a week for one week -Effective 3/5/23, SNV once a week for seven weeks. -Effective 3/20/23 to 3/25/23, HHVA once a week for one week. -Effective 3/26/23 to 4/22/23, HHAVs twice a week for four weeks. Review of the clinical record indicated a missed SNV note, dated 2/23/23. The note did not indicate the Physician was notified of the missed SNV. Review of the clinical record indicated no HHAV was provided, as ordered, from 3/20/23 to 3/25/23, and there was no documented evidence that the Physician was notified the HHAV was not provided. Further review of the record indicated a HHAV was refused by Patient #2 on 3/27/23, and a second visit was not provided, as ordered, during the week of 3/26/23 to 4/1/23. The record did not indicate any documented evidence the Physician was notified that a second HHAV was not provided, as ordered, during the week of 3/26/23 to 4/1/23. c. Review of the Physician orders for certification period, 4/23/23 through 6/21/23, indicated the following: -One PRN SNV. -Effective 4/23/23, SNV once a week for nine weeks. Review of the clinical record indicated missed SNV notes, dated 4/22/23 and 5/11/23. The notes did not indicate the Physician was notified of the missed SNVs. During an interview on 5/23/23 at 3:40 P.M., after reviewing the clinical record, the Quality Director said the plan of care was not followed and the Physician should have been notified that the HHAVs and the SNVs were not provided, as ordered. 2. Patient #13 was admitted to the Agency in December 2022 with a diagnosis of Focal Partial Idiopathic Epilepsy (seizures that affect a single brain area). Review of the clinical record indicated a Skilled Nurse Discharge Outcome and Assessment Information Set (OASIS-a comprehensive assessment) was completed on 1/27/23. There was no documentation found in the clinical record to indicate the Physician had been notified of the Patient's discharge from the Agency before the Physician ordered certification period. During an interview on 5/23/23 at 2:30 P.M., after reviewing Patient #13's clinical reocrd, the Quality Director said there was no documentation found to indicate the Physician had been notified of the Patient's discharge from the Agency, as required.