VNA of Cape Cod

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure patients be informed about, and consent or refuse care and services in advance of and during treatment for 2 patients (#13 and #1) out of a total sample of 17 patients. Findings include: 2. Patient #1 was admitted to the agency in November 2025 with a diagnosis of pneumonia. Review of the physician ordered POC for certification period 11/25/25 through 1/23/26 indicated the following: -Home Health Aide (HHA): 2 visits a week for 9 weeks Review of the clinical record indicated HHA visits were completed on 12/1/25, 12/5/25, and 12/8/25. Further review of the clinical record did not indicate consent for HHA services was obtained and signed by Patient #1. During an interview on 1/5/26 at 1:47 P.M., the Executive Director said a HHA consent form was not completed for Patient #1 as required. During an interview on 1/7/26 at 2:48 P.M., the Executive Director said there was no specific policy for consents. She said the agency follows the Patient Handbook which indicates all consents for treatment need to be completed prior to the initiation of services. Review of the agency policy titled “The Patient Handbook”, dated as last approved 4/7/2025, indicated the following: The Patient handbook outlines all of the Organization’s services including, but not limited to eligibility criteria, cost of services, payment options, patient rights and responsibilities, confidentiality of clinical record/record release, health care proxy information, and description of special services and programs. Review of the Patient Handbook, dated 4/2025, included an informational sheet titled “Patient Rights and Responsibilities” which included, but was not limited to the following: Patients have the right to: participate in, and be informed about, and consent or refuse care in advance of and during treatment with respect to: *The care to be furnished, based on comprehensive assessment. *Establishing and revising the plan of care. *The disciplines that will furnish the care. *The frequency of visits and any changes in the care to be furnished. 1.Patient #13 was admitted to the agency in February 2025 with diagnosis of aftercare following surgery for neoplasm, requiring skilled services. Review of the physician ordered Plan of Care (POC) for certification period 2/21/25 through 4/21/25 indicated the following: -Skilled Nursing (SN): 2 visits every week for 9 weeks and 3 visits as needed (PRN) -Medical Social Work (MSW): 1 visit every 30 days for 30 days Review of the clinical record indicated SN visits were completed on 2/21/25, 2/24/25, 2/27/25 and 3/3/25. Additional review of clinical record indicated that a MSW visit was completed on 2/27/25. Further review of the clinical record failed to include any consents for services and care provided. During an interview on 1/7/26 at 11:04 A.M., the Executive Director of Quality, Compliance and Education (Executive Director) said she was unable to locate and provide any signed consents for the care provided to Patient #13.”

“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 and staff interview, the agency failed to ensure staff provided care and services ordered by the physician as indicated in the Plan of Care (POC) for 4 patients (#3, #5, #12, and #4), out of a total sample of 17 patients. Findings include: 4. Patient # 4 was admitted to the agency in November 2025 with diagnosis of chronic obstructive pulmonary disease and required skilled care. Review of the physician ordered POC for certification period 11/7/25 through 1/5/26 indicated the following: -SN visits one time every week for 9 weeks and 3 visits as needed -HHA visits 2 times every week for 4 weeks, with a physician order date of 12/7/25 for start of service Review of the clinical record indicated no documented evidence that a SN visit was provided the week of 11/16/25 with no indication as to why the visit was not provided as ordered. Review of all home care visits provided between 12/7/25 through 1/5/26 indicated no documented evidence any HHA visits were provided per physician’s orders with no indication as to why the visits were not provided. During an interview on 1/7/26 at 10:58 A.M., the Executive Director, after reviewing Patient #4’s clinical record, said the physician ordered POC was not followed for providing SN visits as ordered. In addition, the Executive Director said the SN discontinued the physician orders for HHA visits as of 12/11/25 with no documented evidence why the orders were discontinued and no indication the physician was notified so HHA visits were not provided. Review of the agency’s policy titled, Patient Care Planning, revised 4/29/24, indicated the following: *Ongoing patient care is provided according to physician’s/non-physician practitioner (NPP) orders and clinical care plans, which are based on individual skilled discipline assessment and patient participation. 1. Patient #3 was admitted to the agency in November 2025 with a diagnosis of aphasia (disorder that affects how you communicate) following cerebral infarction (happens when a blood clot blocks an artery in the brain, cutting off oxygen and nutrients, causing brain tissue to die). Review of the physician ordered Plan of Care (POC) for certification period 11/5/25 through 1/3/26 indicated the following: -Speech Language Pathology (SLP) visits one time every 30 days for 30 days, 2 times a week for 2 weeks (11/9/25 to 11/22/25), then once a week for 6 weeks (11/23/25 to 1/3/26) Review of the clinical record indicated no documented evidence that a second SLP visit was completed the week of 11/16/25 to 11/22/25. During an interview on 1/7/26 at 11:00 A.M., the Executive Director of Quality, Compliance and Education (Executive Director), after reviewing Patient #3’s clinical record, said that the physician ordered Plan of Care was not followed for providing SLP visits, as required. 2. Patient #5 was admitted to the agency in November 2025 with a diagnosis of atrial fibrillation (irregular heartbeat). Review of the physician ordered POC for certification period 11/22/25 through 12/3/25 indicated the following: -Home Health Aide (HHA) visits twice a week for 8 weeks Review of the clinical record indicated no documented evidence that a second HHA visit was completed the week of 11/30/25 through 12/6/25. During an interview on 1/7/26 at 11:06 A.M., the Executive Director, after reviewing Patient #5’s clinical record, said that the physician ordered Plan of Care was not followed for providing HHA visits, as required. 3. Patient #12 was admitted to the agency in November 2025 with a diagnosis of pyonephritis (severe form of kidney infection). Review of the physician ordered POC for certification period 11/10/25 through 1/8/26 indicated the following: -Skilled Nurse (SN) visits twice a week for 21 days (11/10/25 to 11/30/25) then once a week for 39 days (12/1/25 to 1/8/26), and 6 visits as needed Review of the clinical record indicated no documented evidence that a second SN visit was completed the week of 11/23/25 to 11/29/25. During an interview on 1/7/26 at 10:23 A.M., the Executive Director, after reviewing Patient #12’s clinical record, said that the physician ordered Plan of Care was not followed for providing SN visits, 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 there was communication shared with the physician when services were not provided, as ordered, for 5 patients (#1, #3, #5, #12, and #4), out of a total sample of 17 patients. Findings include: 5. Patient # 4 was admitted to the agency in November 2025 with diagnosis of chronic obstructive pulmonary disease and required skilled care. Review of the physician ordered POC for certification period 11/7/25 through 1/5/26 indicated the following: -SN visits one time every week for 9 weeks and 3 visits as needed. -HHA visits 2 times every week for 4 weeks, with a physician order date of 12/7/25 for start of service. Review of the clinical record indicated no documented evidence that a SN visit was provided the week of 11/16/25 with no indication as to why the visit was not provided as ordered and no indication the physician had been notified. Review of all home care visits provided between 12/7/25 through 1/5/26 indicated no documented evidence any HHA visits were provided per physician’s order with no indication as to why the visits were not provided and no indication the physician had been notified. During an interview on 1/7/26 at 10:58 A.M., the Executive Director, after reviewing Patient #4’s clinical record, said the physician ordered POC was not followed for providing SN visits as ordered and the physician had not been notified. In addition, the Executive Director said the SN discontinued the physician orders for HHA visits as of 12/11/25 with no documented evidence why the orders were discontinued and no indication the physician had been notified. Review of the agency’s policy titled Patient Care Planning, revised 4/29/24, indicated but was not limited to the following: *Ongoing patient care is provided according to physician’s/non-physician practitioner (NPP) orders and clinical care plans, which are based on individual skilled discipline assessment and patient participation. *The Plan of Care is reviewed every sixty (60) days and prn (as needed) by each skilled discipline. This review is based on patient assessment, or whenever there is a significant change in patient’s condition, diagnosis, environment, equipment or support system. All changes are reported to the patient’s physician or NPP, the VNA interdisciplinary team and the patient/family representative. 1. Patient #1 was admitted to the agency in November 2025 with a diagnosis of pneumonia. Review of the physician ordered Plan of Care (POC) for certification period 11/25/25 through 1/23/26 indicated the following: -Skilled Nurse (SN) visits twice a week for 2 weeks (11/25/25 to 12/6/25), once a week for 1 week (11/30/25 to 12/6/25), then once a week for 7 weeks (12/7/25 to 1/23/26) -Physical Therapy (PT) visits once every 30 days for 30 days then once a week for 7 weeks (12/7/25 to 1/23/26) Review of the clinical record during the week of 12/14/25 to 12/20/25 indicated canceled SN and PT visit notes, both dated 12/16/25. Further review of the clinical record contained no documentation that the physician had been notified of the canceled visits. During an interview on 1/5/26 at 1:47 P.M. and 2:48 P.M., the Executive Director, after reviewing Patient #1’s clinical record, said there was no documentation in the clinical record that the physician had been notified of the canceled SN and PT visits, as required. 2. Patient #3 was admitted to the agency in November 2025 with a diagnosis of aphasia (disorder that affects how you communicate) following cerebral infarction (happens when a blood clot blocks an artery in the brain, cutting off oxygen and nutrients, causing brain tissue to die). Review of the physician ordered Plan of Care (POC) for certification period 11/5/25 through 1/3/26 indicated the following: -Speech Language Pathology (SLP) visits one time every 30 days for 30 days, 2 times a week for 2 weeks (11/9/25 to 11/22/25), then once a week for 6 weeks (11/23/25 to 1/3/26) Review of the clinical record indicated no documented evidence that a second SLP visit was completed the week of 11/16/25 to 11/22/25. Further review of the clinical record contained no documentation that the physician had been notified of the missed visit. During an interview on 1/7/26 at 11:00 A.M., the Executive Director, after reviewing Patient #3’s clinical record, said there was no documentation in the clinical record that the physician had been notified of the missed SLP visit, as required. 3. Patient #5 was admitted to the agency in November 2025 with a diagnosis of atrial fibrillation (irregular heartbeat). Review of the physician ordered POC for certification period 11/22/25 through 12/3/25 indicated the following: -SN visits once a week for 9 weeks (11/22/25 to 1/17/26) and 4 visits as needed Review of the clinical record indicated a 12/23/25 SN canceled visit note. Further review of the clinical record contained no documentation that the physician had been notified of the missed visit. During an interview on 1/7/26 at 3:00 P.M., the Executive Director, after reviewing Patient #5’s clinical record, said there was no documentation in the clinical record that the physician had been notified of the missed SN visit, as required. 4. Patient #12 was admitted to the agency in November 2025 with a diagnosis of pyelonephritis (severe form of kidney infection). Review of the physician ordered POC for certification period 11/10/25 through 1/8/26 indicated the following: -Skilled Nurse (SN) visits twice a week for 21 days (11/10/25 to 11/30/25) then once a week for 39 days (12/1/25 through 1/8/26), and 6 visits as needed Review of the clinical record indicated no documented evidence that a second SN visit was completed in the weeks of 11/16/25 to 11/22/25 and 11/23/25 to 11/29/25. Further review of the clinical record contained no documentation that the physician had been notified of the missed visits. During an interview on 1/7/26 at 10:23 A.M., the Executive Director, after reviewing Patient #12’s clinical record, said there was no documentation in the clinical record that the physician had been notified of the missed SN visits, as required.”