Visiting Home Nurses, Inc.

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients’ initial assessment was completed within 48 hours of the physician’s referral date or on the physician-ordered start of care date for one of seven sampled patients (Patient 4). This failure had the potential to cause a delay in the determination of Patients 4’s immediate care and support needs. Findings: A review of Patient 4’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of March 30, 2025, with a certification period of March 30, 2025, to May 28, 2025. Patient 4 had diagnoses that included pneumonia (a lung infection). A review of Patient 4’s physician’s referral order dated March 27, 2025, indicated, “Discharged today on home health for physical therapy, medication management and safety evaluation.” A review of Patient 4’s initial assessment, dated March 30, 2025, indicated the initial assessment had been conducted on March 30, 2025. The initial assessment had been completed three days after the physician’s referral order. A review of a Communication Note, dated March 28, 2025, indicated, “Patient and family requested for visit to be done on Sunday, [Primary Medical Doctor] aware.” During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on June 4, 2025, at 1:52 PM, the Admin/DPCS stated after learning of Patient 4 and family’s request, the Admin/DPCS would not confirm or deny that a physician’s order had been obtained for the new start of care date. A review of the agency’s policy and procedure titled “Initial and Comprehensive Assessment,” dated January 2008, indicated, “POLICY: …The initial assessment visit must be performed either within 48 hours of the referral, within 48 hours of the patient’s return home, on the start of care date ordered by the physician, … or at the patient/family request with the approval of the physician.””

“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 observation, interview, and record review, the agency failed to ensure a review of all the medications the patients were taking was conducted for one of seven sampled patients (Patient 1) when the Medication Profile (MP), indicated: a. Fluocinonide external (a topical medication applied to the skin to reduce inflammation, swelling, and itching) 0.05 (five)% (percent) apply to scalp daily and Patient 1’s wife stated the fluocinonide was stopped one week ago and Patient 1 was now using [Brand Name] shampoo. b. Systane eye drops (artificial tears designed to relieve dry eye symptoms), instill (to put in) 2 (two) drops into each eye 2 times daily and Patient 1’s wife stated she was instilling 1 (one) drop in each eye, 3 (three) times daily for the past 2 weeks as directed by the doctor. c. Tacrolimus external (a topical medication applied to dry and itchy patches of the skin) 0.1%. Apply to skin rash 2 times daily as needed and Patient 1’s wife stated Patient 1 was not using the tacrolimus but did not remember went it was stopped. d. Clobex spray external (a topical medication applied to the skin to reduce inflammation and itching) 0.05%, 59 ml (milliliters-a unit of measurement) spray to affected area(s) 2 times daily as needed. The MP did not indicate the special instructions on the pharmacy label which indicated, “Apply to affected areas on body twice daily after moisturizing cream twice. Take at least one week break before reapplying cycle, avoid face.” This failure had the potential to cause Patient 1 to suffer ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: A review of Patient 1’s care plan (contains information about a patient’s diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of December 29, 2023, with a recertification period of April 22, 2025, to June 20, 2025. Patient 1 had diagnoses that included non-rheumatic mitral valve disorder (a condition where the mitral valve, which separates the two left chambers of the heart, becomes damaged due to weakening of the valve tissue, leading to leakage of blood across the valve). During a home visit on June 3, 2025, with the Administrator/Director of Patient Care Services (Admin/DPCS) and Patient 1’s wife, an observation of Patient 1’s actual medication bottles available in the home were compared with Patient 1’s most current Medication Profile (MP). During a concurrent observation and interview on June 3, 2025, from 10:54 AM, to 11:16 AM with the Admin/DPCS and Patient 1’s wife: The Admin/DPCS and Patient 1’s wife confirmed a Registered Nurse (RN 1) had visited Patient 1 and reviewed all his medications yesterday (June 2, 2025). a. The MP indicated fluocinonide external 0.05%, apply to scalp daily. Patient 1’s wife stated Patient 1 had been using the fluocinonide for a long time but stopped last Tuesday (May 27, 2025) and Patient 1 was now using [Brand Name] shampoo. b. The MP indicated Systane eye drops instill 2 drops into each eye, 2 times daily. Patient 1’s wife stated she was instilling 1 drop in each eye, 3 times daily for the past 2 weeks as directed by the doctor. c. The MP indicated tacrolimus external 0.1%. Apply to skin rash 2 times daily as needed. Patient 1’s wife stated Patient 1 was not using the tacrolimus but did not remember went it was stopped. d. The MP indicated Clobex spray external 0.05%, 59 ml spray to affected area(s) 2 times daily as needed. Patient 1’s wife provided the pharmacy labeled packaging for the Clobex spray and the pharmacy label indicated “Apply to affected areas on body twice daily after moisturizing cream twice. Take at least one week break before reapplying cycle, avoid face.” The MP did not indicate the special instructions indicated on the pharmacy label. The Admin/DPCS confirmed the discrepancies on the MP and stated RN 1 should have updated the MP with the information provided by Patient 1’s wife at her visit on June 2, 2025. During an interview with RN 1 on June 3, 2025, at 12:45 PM, RN 1 stated the Admin/DPCS asked her to visit Patient 1 on June 2, 2025, and review Patient 1’s medications. RN 1 stated she had spoken to Patient 1 about his medications, not Patient 1’s wife and Patient 1 did not tell her about the changes for the fluocinonide, Systane eye drops, or tacrolimus external. RN 1 stated she had not looked at the pharmacy label for the Clobex spray and was unaware of the special instructions. A review of the agency’s policy and procedure titled “Medication Profile,” dated January 2008, indicated, “PURPOSE: To define the use of the medication profile in evaluating a patient’s medication regimen. POLICY: Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Procedure: … 4. During subsequent home 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. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications C. Using the medication profile as a communication tool for other clinicians involved in care.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the patients’ clinical record included all the physician’s orders for one of seven sampled patients (Patient 1) when Patient 1’s referral order was not in Patient 1’s clinical record. This failure had the potential to cause Patient 1 not to receive the prescribed care, the inability of healthcare providers to track the patient’s treatment plan over time, and a lack of clear records for legal and regulatory purposes. Findings: A review of Patient 1’s care plan (contains information about a patient’s diagnosis, the goals of treatment, and specific nursing orders), undated, indicated a start of care date of December 29, 2023, with a recertification period of April 22, 2025, to June 20, 2025. Patient 1 had diagnoses that included non-rheumatic mitral valve disorder (a condition where the mitral valve, which separates the two left chambers of the heart, becomes damaged due to weakening of the valve tissue, leading to leakage of blood across the valve). A review of Patient 1’s physician’s orders from December 29, 2023, to June 2, 2025, was conducted. There was no documented evidence to show a physician’s referral order for home health services had been received. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on June 2, 2025, at 4 PM, the Admin/DPCS confirmed a physician’s referral order was not in Patient 1’s clinical record. A review of the agency’s policy and procedure titled “Entries into the Clinical Record,” dated January 2008, indicated, “POLICY: Home health personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The record format will be reviewed and updated as necessary. PROCEDURE: 1. A clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: … C. Physician (or other authorized licensed independent practitioner) orders and evidence of physician oversight activities. …””

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the clinical record contained a completed discharge summary sent to the Primary Care Practitioner (PCP) within five business days of the patient’s discharge for one of seven sampled patients (Patient 6). This failure had the potential to cause Patient 6’s physician being unaware of the patient’s status, including problems identified at admission and during care, progress towards goals, medical status at discharge, and continuing symptom management needs. Findings: A review of Patient 6’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 26, 2024, with a recertification period of February 24, 2025, to April 24, 2025. Patient 6 had diagnoses that included open wound to scalp. Patient 6 was discharged on April 14, 2025. A review of Patient 6’s discharge order dated April 15, 2025, indicated “Per [Skilled Nurse] … report dated [April 15, 2025], [Patient 6] was admitted to a behavioral hospital (hospital name not disclosed) secondary to [Patient 6] trying to commit suicide by cutting his skin wrist, this report to [SN] was given by [Patient 6’s] father … Discharge [Patient 6] from [name of agency] secondary to patient admission to the hospital effective [April 14, 2025].” A review of Patient 6’s discharge summaries from December 26, 2024, to June 4, 2025, was conducted. There was no documented evidence to show a discharge summary had been completed and sent to the PCP. A review of Patient 6’s discharge assessment dated April 14, 2025, was conducted. There was no documented evidence to show the discharge assessment contained: a. The status of problems identified at admission and during the provision of care. b. The progress toward goals/desired outcomes. c. Medical status at discharge, including continuing symptom management needs. d. The overall status of the patient. e. A summary of care or services provided. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on June 4, 2025, at 4:19 PM, the Admin/DPCS stated Patient 6’s discharge assessment was considered as Patient 6’s discharge summary. The Admin/DPCS refused to confirm or deny that the discharge assessment contained: the status of problems identified at admission and during the provision of care, the progress toward goals/desired outcomes, medical status at discharge, including continuing symptom management needs, the overall status of the patient, or a summary of care or services provided or that a discharge summary had been sent to the PCP within five days of Patient 6’s discharge. A review of the agency’s policy and procedure titled “Discharge Summary,” dated January 2008, indicated, “PURPOSE: To define requirements for documentation of service discontinuation and when patients are discharged from the organization. POLICY: Each patient discharged from a service and from the organization will have a written discharge summary filed in the clinical record. PROCEDURE: 1. Each clinician who provides care will complete a discharge summary at the time his/her discipline is discharged, which may include, as appropriate: … D. The status of problems identified at admission and during the provision of care. E. The progress toward goals/desired outcomes. F. Medical status at discharge, including continuing symptom management need. G. The overall status of the patient. H. A summary of care or services provided. 2. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from service. 3. A copy of the discharge summary will be provided to the patient’s physician, when requested.””