South Shore Visiting Nurse Association

“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 record review, policy review and interview, the agency failed to ensure one Patient (#7) had the right to participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, out of a total sample of 17 patients. Findings include: Review of the agency’s policy entitled Acceptance for Service-Home Care Division Policy, revised January 2025, included but was not limited to the following: *All patients must document their Acceptance for Services prior to the establishment and initiation of the Plan of Care. Patient’s Acceptance for Services is documented on the Authorization to Release Information and Payment Consent for Care. Patient #7 was admitted to the agency in September 2025 with a diagnosis of type 2 diabetes mellitus with foot ulcer requiring skilled services. Review of the physician ordered Plan of Care (POC) for certification period 9/19/25 through 11/17/25 indicated the following: Skilled Nursing (SN): 1 visit every week for 1 week (9/19/25 to 9/20/25), 3 visits as needed (PRN) (9/19/25 to 11/17/25), then 2 visits every week for 9 weeks (9/21/25 to 11/17/25) Review of the clinical record indicated SN visits were completed as physician ordered. Review of the physician ordered POC for certification period 11/18/25 through 1/16/26 indicated the following: SN: 2 visits every week for 9 weeks (11/18/25 to 1/16/26), discontinued as of 12/5/25, then resumed 3 visits every week for 6 weeks (12/7/25 to 1/16/26) Review of the clinical record indicated SN visits were completed as physician ordered. Review of the physician ordered POC for certification period 1/17/26 through 3/17/26 indicated the following: SN: 3 visits every week for 10 weeks (1/17/26 to 3/17/26) and 3 visits PRN (1/17/26 to 3/17/26) Review of the clinical record indicated SN visits were completed as physician ordered. Further review of the clinical record failed to include any consent by Patient #7 to receive skilled nurse services. During an interview on 2/12/26 at 2:02 P.M., the Clinical Director said she was unable to locate and provide a signed acceptance for SN services for Patient #7 prior to receiving the services, as required.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded 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 all patient care orders, including verbal orders, were recorded in the plan of care for one patient (#7) out of a total sample of 17 patients. Findings include: Review of the agency’s policy titled Home Care Guideline: Plan of Care-Physician’s Orders, revised September 2025, included but was not limited to the following: *The individualized plan of care must include the following: -All medications and treatments. -All patient care orders, including verbal orders, must be recorded in the plan of care. Review of the agency’s policy titled Home Care Procedure: Medical Record Documentation, revised September 2025, included but was not limited to the following: *Each patient record shall include the following, as appropriate to the care, treatment, and services: Medication Management: -Complete medication list, including dose, frequency, and route of administration of current prescription and non-prescription medications and herbal products. -Medication regimen, including current, changed, and discontinued medications. -Medication reconciliation. Additional Information: -Authenticated, legible, and completed physician’s orders. Patient #7 was admitted to the agency in September 2025 with diagnoses of type 2 diabetes mellitus with foot ulcer requiring skilled home care services. Review of the Transfer/Discharge Report, dated 9/18/25, indicated the following medication order: -Insulin Aspart Subcutaneous Solution Pen-Injector 100 Unit/Milliliter (ml). Directions: Inject as per sliding scale (SC-reactive, short-acting insulin regimen designed to manage blood sugar levels, typically by adjusting dosages based on pre-meal or every 6-hour blood glucose readings). If 150-200 = 2 units 201-250 = 4 units 251-300 = 6 units 301-350 = 8 units less than 71 or greater than 350 notify MD/NP for further orders, subcutaneously three times a day before meals Review of the Endocrine Clinic Progress Note, dated 1/30/26, indicated the following medication order: -Mealtime Insulin 201-250 3 units 251-300 4 units 301-350 5 units >350 6 units Review of the physician ordered Plan of Care (POC) for certification periods 9/19/25 through 11/17/25, 11/18/25 through 1/16/26, and 1/17/26 through 3/17/26 indicated the following: *Insulin Aspart FlexPen 100 Unit/ml solution pen-injector. Sig. Inject under the skin three times a day as needed (glucose levels). According to sliding scale. Route: Subcutaneous. Further review of the physician ordered POCs failed to include physician orders for sliding scale protocol. During a home visit interview on 2/11/26 at 11:56 A.M., Patient #7 asked Nurse #1 to refresh his/her memory on what the insulin SC parameters were as he/she self-injected and could not locate the parameters. Nurse #1 assisted the patient in finding the parameters on an outside physician visit summary the patient possessed and said she would need to add them to the current POC as the order was incomplete and did not include them. During an interview on 2/11/26 at 12:52 P.M., the Clinical Director, after reviewing Patient #7’s clinical record, said the insulin Aspart FlexPen order was incomplete on the POC and should have reflected the SC parameters initially from the transfer orders then updated after endocrinologist’s visit on 1/30/26.”