Holyoke Visiting Nurse Assoc

“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, document review and interview, the agency failed to ensure infection control guidelines were maintained during the home visit observations for disinfecting the medical equipment after use, for 4 patients (#6, #10, #12 and #7), out of a total sample of 7 patient home visits. Findings include: 4. Patient #7 was admitted to the agency in March 2026 with a diagnosis of vascular dementia (decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving it of oxygen and nutrients). Review of the physician ordered Plan of Care (POC) for certification period 5/1/26 through 6/29/26 indicated the following: *Occupational Therapy (OT): once every week x 8 weeks On 5/5/26 at 11:30 A.M., the surveyor observed OT #1 obtain vital signs including blood pressure, pulse, and temperature from Patient #7. OT #1 placed the vital signs equipment including his stethoscope, blood pressure cuff, and handheld thermometer on top of a barrier that was placed on the patient’s living room table after use. OT #1 sprayed partial surfaces of the observed equipment with an unlabeled disinfectant then placed the equipment into his bag. OT #1 did not adequately disinfect the equipment after use. During an interview on 5/5/26 at 12:10 P.M., OT #1 said he was not sure what type of disinfectant was in the spray bottle and said all surfaces of the equipment should have been properly disinfected. During an interview on 5/6/26 at 2:20 P.M., the Director of Quality Improvement and Director of Home Care said clinicians are required to disinfect equipment after use with alcohol pads, alcohol spray, or Vyrex spray (ready-to-use hospital grade disinfectant) and should spray, wipe down all surfaces, and leave the equipment to dry. During an interview on 5/7/26 at 2:45 P.M., the Director of Quality Improvement said the agency did not have a policy for disinfection of equipment. Review of the Association for Professionals in Infection Control and Epidemiology (APIC) guide titled Strategies to Mitigate Cross Contamination of Non-critical Medical Devices, dated 2021, indicated but was not limited to the following: Cleaning and Disinfecting Medical Equipment *The Occupational Safety and Health Administration’s (OSHA’s) bloodborne pathogens standard, 29 CFR 1910.1030, requires that items and surfaces contaminated with blood or other potentially infectious materials be decontaminated with an appropriate disinfectant. OSHA does not provide its own definition of an “appropriate disinfectant”; instead, OSHA defers to the U.S. Environmental Protection Agency (EPA)… Use of the various product lists published by the EPA can assist in selection of an appropriate disinfectant for the needs of the healthcare setting. *Other considerations when selecting disinfectants include their flammability, corrosiveness, stability, and required contact time. Contact time, also known as “wet time”, is the amount of time the surface must be wet to ensure efficacy of the disinfectant. Contact time is determined by the manufacturer… *Once a compatible and appropriate disinfectant is selected for use, the staff responsible for disinfection must understand and execute the correct technique for the disinfectant application as explained in the manufacturer’s instructions… For example, disinfectant wipes and sprays are commonly used to disinfect medical equipment because they are easy to use and can perform reliably. However, improper use of these products can diminish their effectiveness. There is potential to transfer microorganisms to other parts of the equipment depending on the bactericidal activity of the disinfectant and the application techniques. Review of the Nursing Bag Technique Competency Evaluation (A Briggs Healthcare form-in lieu of a policy) indicated but was not limited to the following: *Equipment used is cleaned prior to returning to bag if appropriate. 1.Patient #6 was admitted to the agency in April 2026 with a diagnosis of neurocognitive disorder with Lewy-bodies (type of Dementia), Dysphagia (difficulty swallowing) and Aphasia (difficulty with communication) and required home health care services. During a home visit on 5/5/26 at 3:31 P.M., the surveyor observed the Speech Language Pathologist (SLP) place a clean field down on a table and remove her thermometer and pulse oximeter (a non-invasive device placed on a finger that measures the percentage of oxygen in the blood and pulse rate) and placed them on a clean field. The patient then told the SLP that the Skilled Nursing did not visit today, so the SLP told the patient that she would take his/her blood pressure and removed the Blood Pressure cuff and stethoscope from her bag and placed it onto the clean field. The SLP completed taking the patients vital signs and placed the above equipment back into her bag without disinfecting the thermometer, blood pressure cuff, stethoscope or the pulse oximeter. During an interview on 5/5/26 at 4:36 P.M. the SLP said that she did not disinfect the above equipment prior to placing it back into her bag, as required, but should have. 2. Patient #10 was admitted to the agency in July 2025 with a diagnosis Non-Pressure Ulcers of the left and right foot, right inner and outer ankle and right lower leg and required home health care services. During a home visit on 5/6/25 at 9:50 A.M. the surveyor observed the Licensed Practical Nurse (LPN #1) remove his Blood pressure cuff, stethoscope, pulse oximeter and thermometer out of his bag and place on a clean field. LPN #1 took the patients vital signs and placed the equipment back on the clean field. LPN #1 performed wound care and placed the equipment back in his bag. The surveyor did not observe him disinfecting the above, During an interview on 5/6/26 at 10:25 A.M. the surveyor said to LPN #1 that she had not observed him disinfecting the blood pressure cuff, stethoscope (which was now hanging around the LPN’s neck), thermometer and pulse oximeter. LPN #1 said that he sprayed a 7% alcohol solution on the items. He also said that he did not disinfect the thermometer because it did not touch the patient’s skin. The surveyor then asked about the stethoscope, and he said he did the bell and only the side of the bell that came in contact with the patient. The surveyor did not observe the LPN disinfect all surfaces of the equipment thoroughly prior to placing it back into the bag. 3. Patient #12 was admitted to the agency in April 2026 with a diagnosis of primary osteoarthritis of the right shoulder and required home health care services. During a home visit on 5/6/26 at 11:20 A.M. the surveyor observed the Physical Therapy Assistant (PTA #1) remove his Blood pressure cuff, stethoscope, pulse oximeter out of his bag and place on a clean field. PTA #1 took the patients vital signs and placed the equipment back onto the clean field. He also took the thermometer directly out of his bag and placed it back in the bag immediately after use. The rest of the equipment that had been used was placed back into the bag without the surveyor observing the disinfecting of the equipment. During an interview on 5/6/26 at 12:30 P.M. the surveyor asked the PTA #1 about the disinfection process, and he said that he did disinfect and showed the surveyor an alcohol prep pad. The small alcohol prep pad was not large enough or contain enough solution to properly disinfect all the surfaces. The PTA said that the agency provides more appropriately sized alcohol wipes specifically for disinfection of the equipment and will obtain them.”

“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 2 patients (#8 and #9), out of a total sample of 17 patients. Findings included: Review of the agency’s policy titled Clinical Documentation, undated, indicated but was not limited to the following: *Documentation of services ordered on the plan of care will be completed by the end of business day, the day after service is rendered and incorporated into the clinical record within seven (7) days after the care has been provided. 1. Patient #8 was admitted to the agency in March 2026 and had a diagnosis of acute respiratory failure. Review of the Physician ordered Plan of Care (POC) for certification period 3/13/26 through 5/11/2026, indicated the following: *Skilled Nurse (SN) visits: 2 every week x 2 weeks then once a week x 7 weeks *Home Health Aide (HHA) visits: twice a week x 8 weeks then once a week x 1 week *Speech Therapy (ST) visits: 1 within 5 days Review of the clinical record indicated the following: *3/17/26 ST visit, note was signed on 3/23/26. *3/19/26 Licensed Practical Nurse (LPN) visit, note was signed on 3/22/26. *3/24/26 HHA visit, note was signed on 3/30/26. *3/27/26 HHA visit, note was signed on 3/30/26. *4/14/26 HHA visit, note was signed on 4/20/26. *4/20/26 HHA visit, note was signed on 4/23/26. *4/23/26 LPN visit, note was signed on 4/26/26. *4/24/26 HHA visit, note was signed on 4/27/26. 2. Patient #9 was admitted to the agency in April 2026 with a diagnosis of displaced fracture of anterior wall of right acetabulum (severe hip injury where the front part of the socket breaks and moves out of place, often resulting from high-velocity impact). Review of the physician ordered POC for certification period 4/18/26 through 6/16/26, indicated the following: -SN visits: twice a week x 2 weeks then once a week x 7 weeks with 4 visits as needed (prn) Review of the clinical record indicated the following: *4/24/26 SN visit, note was signed on 4/27/26. During an interview on 5/6/26 at 2:35 P.M., after reviewing the clinical records for patients #8 and #9, the Director of Quality Improvement and Director of Home Care said the clinical notes were not completed within the required timeframe.”

“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 record review and interview, the agency failed to ensure the initial assessment visit was completed within 48 hours of the referral date for 1 patient (#12) in a total sample of 17 patients. Findings include: Review of the agency’s policy titled Comprehensive Patient Assessment, undated, indicated but was not limited to the following: *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 ordered start of care date. Patient #12 was admitted to the agency in April 2026 with a diagnosis of primary osteoarthritis of the right shoulder and required home health care services. Review of the clinical record indicated a referral for home care services was received on 4/8/26 and the physician’s order was as follows: Visit order: Nursing, Registered Nurse Visit Frequency: Effective 4/9/26 for 1 visit withing two days for 2 days. Skilled Nurse (SN) to assess/teach. An agency communication note, dated 4/9/26, indicated that the patient declined the visit, states she just came home and would like the day to settle in and rest. MD and HVNA intake notified of missed visit. SN request new order for admission from MD. An agency communication note, dated 4/14/26, indicated that multiple attempts to contact patient have been unsuccessful. Voice Message left today with VNA number. Attempted to reach Emergency Contact (EC) but no answer and it was not until 4/16/26 that the initial admission assessment was completed. Further review of the medical record indicated that a new order for the initial admission assessment had not been obtained from the physician. During an interview on 5/7/26 at 3:30 P.M., the Director of Quality Improvement said that there was no documentation in the medical record indicating that a new order for the initial admission assessment had been obtained from the physician. She also said that the documentation in the medical record should have been more detailed as to the multiple attempts and indicating why there was a delay in the start of care. She said that the start of care should be within 48 hours of receiving the referral and it was not.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure treatments were administered only as ordered by a physician or allowed practitioner for 1 patient (#10), out of a total sample of 17 patients. Findings include: Based on record review and interview, the home health agency failed to ensure treatments were administered only as ordered by a physician or allowed practitioner for 1 patient (#10), out of a total sample of 17 patients. Findings include: 1. Patient # 10 was admitted to the agency in July 2025 with a diagnosis of non-pressure ulcers of both feet, right ankle, and calf area. Review of the Physician ordered Plan of Care for certification period 5/2/26 through 6/30/26 indicated the following wound care orders: -3xweek/30 days. Discharge Instructions: Cleanse with Normal Saline (NS) as instructed – PeriWound care: Secure extra protective cream, tube -3x/week/30 days. Discharge Instructions: 25% or greater Zinc Oxide – purchase at pharmacy. --Primary dressings: Aquacel AG advantage (advanced antimicrobial primary wound dressing that uses hydro Fiber technology and ionic silver to manage exudate, kill bacteria and maintain a moist wound environment for healing) dressing, 4x5 in/in 3x/week/30 days. Discharge Instructions: Apply over Adaptic (non-adherent wound dressing) – Primary Dressing: Curad non adherent Petroleum Gauze Dressing (provides a moist healing environment while preventing sticking to the wound bed) 3x9 in/in 3x/week/30 days. Discharge Instructions: Apply to wound bed -Secondary Dressing: Zetuvit Absorbent Pad (sterile, superabsorbent dressing) 4x4 in/in 3/week/30 days - Secured with: Conforming Stretch Gauze Bandage 4x75 in/in 3xweek/30 days. Discharge Instructions: Wrap lightly to secure gauze - Secured with: Tape 1 in paper 3xweek/30 days. Discharge Instructions: Secure with tape – Compression Wrap: Tubigrip Size E 3.5x10 in/yds 3xweek/30 days. Discharge Instructions: Apply prior to getting out of bed -Wound Care Left Foot (5/2/26 - 6/30/26) - Per visit – Wound #5 Foot, Dorsal, Left - Cleanser: Normal Saline 3xweek/30 days. Discharge Instructions: Cleanse with Normal Saline as instructed – PeriWound Care: Secure extra protective cream, Tube 3xweek/30 days. Discharge Instructions: 25% or greater Zinc Oxide (skin protectant)- purchase at pharmacy - Primary Dressing: Aquacel AG Advantage Dressing, 4x5 in/in 3xweek/30 days. Discharge Instructions: Apply over Adaptic – Primary Dressing: Curad non adherent Petroleum Gauze Dressing 3x9 in/in 3x/week/30 days. Discharge Instructions: apply to wound bed - Secondary Dressing: Xtrasorb (highly absorbent) Medium 4x5 in/in 3x/week/30 days. Discharge Instructions: Apply to wound as directed. Do not cut – Secondary Dressing: Zetuvit Absorbent Pad 4x4 in/in 3x/week/30 days – Secured with: Conforming Stretch Gauze Bandage 4x75 in/in 3x/week/30 days. Discharge Instructions: wrap lightly to secure gauze – Secured with: Tape 1 in paper 3x/week/30 days. Discharge Instructions: Secure with tape – Compression Wrap: Tubigrip Size E 3.5/10 in/yds 3x/wee/30 days. Discharge Instructions: Apply prior to getting out of bed Review of the wound care orders did not identify the location of wounds requiring treatment, except for one order specifying wound care to the left dorsal foot (wound #5). During a home care visit observation on 5/6/26 at 10:00 A.M., the surveyor observed Licensed Practical Nurse (LPN #1) perform wound care to the following areas: a). Top of left footb). Top of right footc). Right outer ankled). Right inner anklee). Right lower leg, outer side of calf (2 areas)LPN #1 provided wound care to each area as follows: -Washed each wound with normal saline -Applied Calcium Alginate (used to treat moderate to heavily exudating wounds) as the primary dressing (primary wound dressing is applied directly to the wound bed) to each area observed. LPN #1 said the dressing he had applied was an Alginate. -Applied an absorbent pad as the secondary dressing (covers the primary dressing padding and absorption) to each area observed -Secured each area observed with tape -Assisted the patient to re-apply a conforming stretch bandage (tubular bandage) to each leg to further hold the dressings in place LPN #1 did not provide any peri-wound care during the home visit/wound care observation, according to the physician’s order. Review of the clinical record indicated a note from a wound care provider that indicated that the patient will only allow Durafiber as the primary dressing and the Tubigrip (conforming stretch bandage). Further review of the clinical record did not indicate skilled nurse documentation of an order from the physician for the Durafiber dressing. During an interview on 5/7/26 at 4:30 P.M., the Director of Quality Improvement said the patients POC should reflect the current patient status and current wound orders but did not.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that the physician ordered Plan of Care was followed for two Patients (#1 and #9), out of 17 sampled patients. Findings include: Review of the agency’s policy titled, Nursing Services, dated as revised 5/2024, included but was not limited to the following: *Nursing care will be provided in accordance with the patient’s plan of care, under the supervision of a registered nurse. Review of the Agency’s policy titled Plan of Care, undated, indicated but was not limited to the following: *Home care services are furnished under the supervision and direction of the patient’s physician. The Plan of Care is based on a comprehensive assessment and information provided by the patient/family and health team members… The plan will be consistently reviewed to ensure that patient needs are met, and will be updated as necessary, but at least every sixty (60) days. *The Plan of Care shall be completed in full to include: -Type, frequency, and duration of all visits/services. -Medications, treatments, and procedures. 1. Patient #1 was admitted to the agency in March 2026 and had a diagnosis of diabetes mellitus Type 2 (chronic condition characterized by high blood sugar resulting from the body’s inability to use insulin effectively and, eventually, insufficient insulin production) with foot ulcer. Review of the physician ordered Plan of Care (POC) for certification period 3/13/26 through 5/11/26 indicated the following: *Skilled Nurse (SN) visits: 2 every week for 8 weeks (3/19/26 to 5/9/26) and 3 visits as needed (prn) *Wound Care Right Foot – 3/19/26 – 5/9/26 Per visit – Metatarsal Head 4th, Right Plantar Per Visit Wound #12 Cleanser: Normal Saline, Soap and Water Peri Wound (skin surrounding a wound): Skin Prep Add-On; Orthopedic Felt (for off-loading) Primary Dressing: Hydrofera Blue Ready (antibacterial dressing that maintains a moist wound environment without pre-hydration) (to wound bed) Secondary Dressing: 2 x 2 Gauze Secure with: Medipore Soft Cloth Tape Frequency: 3x Weekly unless going to wound clinic then 2x week: Supplies – Wound Supplies Review of the clinical record indicated the following: Week of 3/29/26 through 4/4/26: -SN visit on 3/30/26 -Missed SN visit on 4/3/26 due to wound clinic appointment -No documented evidence a second SN visit was conducted (two SN visits ordered for wound care if the patient goes to the wound clinic) Review of the Wound Clinic Patient Visit Report received by the agency from the Wound Clinic on 5/6/26 at 9:04 A.M., after surveyor intervention, indicated Patient #7 missed his/her wound clinic appointment on 4/3/26. Week of 4/5/26 through 4/11/26: -SN visits on 4/7/26 and 4/10/26 -No documented evidence of a wound clinic appointment -No documented evidence a third SN visit was conducted (three SN visits ordered for wound care if the patient does not go to the wound clinic) Week of 4/12/26 through 4/18/26: -SN visits on 4/14/26 and 4/17/26 -No documented evidence of a wound clinic appointment -No documented evidence that a third SN visit was conducted (three SN visits ordered for wound care if the patient does not go to the wound clinic) During an interview on 5/5/26 at 3:28 P.M., the Director of Quality Improvement and Director of Home Care said the medical record did not reflect wound clinic visits for the weeks of 4/5/26 through 4/11/26 and 4/12/26 through 4/18/26 and there were only two SN visits conducted each week, not three. They further said they could not locate a second SN visit the week of 3/29/26 through 4/4/26 as ordered. During an interview on 5/6/26 at 1:58 P.M., the Director of Quality Improvement said they didn’t know the patient was not seen at the wound clinic during the weeks of 4/5/26 through 4/11/26 and 4/12/26 through 4/18/26 and had no documentation of the missed visits. 2. Patient #9 was admitted to the agency in April 2026 with a diagnosis of displaced fracture of anterior wall of right acetabulum (severe hip injury where the front part of the socket breaks and moves out of place, often resulting from high-velocity impact). Review of the physician ordered POC for certification period 4/18/26 through 6/16/26, indicated the following: -SN visits: twice a week x 2 weeks (4/19/26) then once a week x 7 weeks (5/3/26), 4 visits PRN Review of the clinical record indicated no documented evidence that a second SN visit was provided the week of 4/26/26 through 5/2/26 as ordered. During an interview on 5/6/26 at 2:27 P.M., the Director of Quality Improvement and Director of Home Care said SN visits were not provided to Patient #9 per the physician ordered POC as required.”

“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, policy review, and interview, the agency failed to ensure staff communicated with all physicians involved in the plan of care (POC) and other health care practitioners (as appropriate) related to the current POC, for one patient (#9), out of total sample of 17 patients. Findings include: Review of the agency’s policy titled Missed or Cancelled Visits, undated, indicated but was not limited to the following: *HVNA and Hospice Life Care has developed guidelines for communication expectations for all staff related to missed or canceled visits to ensure agency resources are efficiently and appropriately assigned and that patients receive the care they need in a timely manner. *Missed visits or cancelled visits can occur for many reasons. Patient may cancel, inclement weather, patient not home, etc. *When a patient misses or cancels visit, the staff will notify their supervisor and the scheduler of the missed visit and the reason for the missed visit, as soon as the staff person is aware of the missed/cancelled visit. *Provider will be notified and missed visit will be documented in EMR per agency policy. Patient #9 was admitted to the agency in April 2026 with a diagnosis of displaced fracture of anterior wall of right acetabulum (severe hip injury where the front part of the socket breaks and moves out of place, often resulting from high-velocity impact). Review of the physician ordered POC for certification period 4/18/26 through 6/16/26, indicated the following: -SN visits: twice a week x 2 weeks (4/19/26) then once a week x 7 weeks (5/3/26), 4 visits PRN (as needed) Review of the clinical record indicated no documented evidence that a second SN visit was provided the week of 4/26/26 through 5/2/26 as ordered. Further review of the clinical record did not contain any documentation of the reason for the missed visit or that the physician had been notified of the missed SN visit. During an interview on 5/6/26 at 2:27 P.M., the Director of Quality Improvement and Director of Home Care said there was no note and no documentation that the physician had not been notified of the missed SN visit, 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 nursing services were provided under the supervision of a registered nurse (RN) in the clinical record for 4 patients (#1, #8, #10 and #11), out of seven patients who received nursing services from a licensed practical nurse (LPN), out of a total sample of 17 patients. 3. Patient #10 was admitted to the agency in July 2025 with a diagnosis of Non-Pressure Ulcers of the left and right foot, right inner and outer ankle and right lower leg Review of the Physician ordered POC for certification periods 3/2/26 through 5/1/26 and 5/2/26 through 6/30/26, indicated the following: Nursing: three visits every week for 9 weeks and 3 prn for wound complications. Review of the clinical record for dates of services between 3/9/26 through 5/6/26 indicated that 9 visits were completed by an LPN. Further review of the clinical record failed to indicate any documented direct or indirect RN supervisory visits including documentation of the competency of the care provided to the patient by the LPN and documentation of input from the caregiver in the home. 4. Patient #11 was admitted to the agency in December 2025 with a diagnosis of Malignant neoplasm of the lung, with a PleurXZ catheter in place (which is a tunneled indwelling catheter system used to manage recurrent fluid buildup around the lungs). Review of the Physician ordered POC for certification period 2/6/26 through 4/9/26 indicated the following: Nursing: three visits every week for 8 weeks, two every week for one week and 4 as needed (prn) for care concerns, disease complications and respiratory complications. Review of the Physician ordered POC for certification period 4/10/26 through 6/8/26 indicated the following: Nursing: one visit every week for 1 week, three visits every week for 8 weeks, one visit every week for one week and 5 prn for care concerns, disease complications and respiratory complications. Review of the clinical record for dates of services between 3/23/26 through 5/6/26 indicated that 8 visits were completed by the LPN. Further review of the clinical record failed to indicate any documented direct or indirect RN supervisory visits including documentation of the competency of the care provided to the patient by the LPN and documentation of input from the caregiver in the home. Findings include: Review of the agency’s policy titled Supervision of Staff: License Practical Nurse Policy, undated, indicated but was not limited to the following: *The agency shall provide Licensed Practical Nurse services under the direction and supervision of a Registered Professional Nurse when services are indicated and ordered by the physician. At least annually, all Licensed Practical Nurses will be supervised directly while providing care. *Purpose: To provide supervision of the Licensed Practical Nurse as required by state/federal guidelines. To assure the quality of services provided by the Licensed Practical Nurse. To ensure the Licensed Practical Nurse is adhering to appropriate standards of practice and following the direction of the Registered Nurse. To assess competency in clinical skill and provide opportunity for review of plan of care with direct input from the caregiver in the home. *The Registered Nurse supervisory visit may be completed directly while the Licensed Practical Nurse is providing service to the patient or indirectly by alternating visits with the LPN and RN. *LPNs will not routinely provide visits to patients with complex medical needs or those requiring complex nursing judgements/assessments, or who require complex teaching. *If the LPN has demonstrated competency in and is assigned to provide care to patients with complex needs, the Registered Nurse will supervise and instruct the LPN on the first day of the assignment and as often as deemed necessary thereafter. 1. Patient #1 was admitted to the agency in March 2026 and had a diagnosis of diabetes mellitus Type 2 (chronic condition characterized by high blood sugar resulting from the body’s inability to use insulin effectively and, eventually, insufficient insulin production) with foot ulcer. Review of the physician ordered Plan of Care (POC) for certification period 3/13/26 through 5/11/26 indicated the following: *Skilled Nurse (SN) visits: 2 every week for 8 weeks (3/19/26 to 5/9/26) and 3 visits as needed (prn) Review of the clinical record for dates of services between 3/27/26 through 4/27/26 indicated LPN visits were conducted on 3/27/26, 3/30/26, 4/7/26, 4/10/26, 4/17/26, and 4/27/26 by LPN #1. Further review of these dates of service did not include any documented direct or indirect RN supervisory visits including monitoring and evaluating the LPN’s performance in the provision of services, provision of treatments, patient education, data collection regarding the patient’s status and health needs, and documentation of input from the caregiver in the home. During an interview on 5/6/26 at 10:05 A.M., LPN #1 said he completes annual competencies but was not aware of any supervisory visits made by a Registered Nurse. 2. Patient #8 was admitted to the agency in March 2026 and had a diagnosis of acute respiratory failure. Review of the Physician ordered POC for certification period 3/13/26 through 5/11/2026, indicated the following: *SN visits: twice a week x 2 weeks then once a week x 7 weeks Review of the clinical record for dates of services between 3/17/26 through 5/4/26 indicated LPN visits were conducted on 3/17/26, 3/19/26, and 4/23/26. Further review of these dates of service did not include any documented direct or indirect RN supervisory visits including monitoring and evaluating the LPN’s performance in the provision of services, provision of treatments, patient education, data collection regarding the patient’s status and health needs, and documentation of input from the caregiver in the home. During an interview on 5/6/26 at 2:35 P.M., after reviewing the clinical records for patients #1 and #8, the Director of Quality Improvement and the Director of Home Care said they follow their policy which states at least annual supervision of LPNs either directly or indirectly. They further said they could not provide documentation of LPN supervision for the dates of service.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure rehabilitation therapy services were provided under the supervision of a physical therapist (PT) for one patient (#8), out of a total sample of 17 patients. Findings include: Review of the agency’s policy titled Supervision of Staff: Physical Therapy Assistant Policy, undated, indicated but was not limited to the following: *At least once annually, all Physical Therapy Assistants will be supervised directly while providing care. *Purpose: To provide supervision of the physical therapist assistant. To assure the quality of services provided by the Physical Therapy Assistant. To ensure the Physical Therapy Assistant is adhering to appropriate standards of practice and following the direction of the Physical Therapist. To assess competency in the clinical skill and provide opportunity for review of plan of care with direct input from the caregiver in the home. * The Physical Therapist Supervisor visit may be completed directly while the Physical Therapy Assistant is providing services to the patient or indirectly by alternating visits with the PTA and PT. Patient #8 was admitted to the agency in March 2026 and had a diagnosis of acute respiratory failure. Review of the Physician ordered Plan of Care (POC) for certification period 3/13/26 through 5/11/2026, indicated the following: *Physical Therapist (PT): twice a week x 6 weeks Review of the clinical record for dates of services between 3/19/26 through 5/4/26 indicated Physical Therapy Assistant (PTA) visits were conducted on 3/19/26, 3/25/26, 3/27/26, 4/1/26, 4/3/26, 4/6/26, 4/20/26, and 4/27/26. Further review of these dates of service did not include any documented direct or indirect PTA supervisory visits including monitoring and evaluating the PTA’s performance regarding provision of treatments, patient education, data collection regarding the patient’s status and health needs, and documentation of direct input from the caregiver in the home. During an interview on 5/6/26 at 2:35 P.M., after reviewing the clinical record, the Director of Quality Improvement and Director of Home Care said the agency follows their policy for PTA supervision at least once annually. They said they could not provide documentation of PTA supervisory visits for the dates of service. During the exit conference on 5/7/26 at 3:00 P.M., the Executive Director said she’s a board member of the Home Care Alliance and provided the surveyor with an email document, dated 5/7/26, from the Home Care Alliance with reference to federal regulation and said they supervise PTAs at least annually per their policy as the federal regulation has no timeframe.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to complete a supervisory assessment of the Home Health Aide (HHA) services being provided no less frequently than every 14 days for 1 patient (#8), out of six patients receiving HHA services out of a total sample of 17 patients. Findings include: Review of the agency’s policy titled Supervision of Staff, undated, indicated but was not limited to the following: *When patients are receiving skilled nursing services in addition to personal care, the Registered Nurse (RN) will make a supervisory visit to the patient’s residence no less frequently than every 14 days. The home health aide would not have to be present for these visits. Patient #8 was admitted to the agency in March 2026 and had a diagnosis of acute respiratory failure. Review of the Physician ordered Plan of Care (POC) for certification period 3/13/26 through 5/11/2026, indicated the following: *HHA visits: twice a week x 8 weeks then once a week x 1 week Review of the clinical record for dates of service between 3/19/26 to 5/1/26 indicated the following: -HHA #1: visits provided on 3/19/26, 4/2/26, and 4/6/26 -HHA #2: visits provided on 3/27/26, 3/31/26, 4/10/26, 4/14/26, 4/20/26, 4/24/26, 4/28/26, and 5/1/26 Further review of these dates of service failed to include any supervisory visits for the HHA services. During an interview on 5/6/26 at 2:35 P.M., after reviewing the clinical record, the Director of Quality Improvement and Director of Home Care said supervisory visits must be conducted every 14 days for HHAs and there should have been supervisory visits provided during the dates of service reviewed.”