Southcoast Visiting Nurse Association Inc.

“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 1 Patient (#9), out of a total sample of 17 patients. Findings include: Review of the agency’s policy entitled Documentation Procedure: Guidelines and Timeliness, revised October 2025, indicated but was not limited to the following: *Purpose – To ensure all clinical documentation is accurate, complete, timely, and compliant with federal and state home health regulations, supporting quality patient care, coordination, and reimbursement. *Timeliness Requirements – Routine Visits (RN, LPN, PT, PTA, OT, COTA, ST); Documentation must be completed the same day of the visit. Patient #9 was admitted to the agency in March 2026 with a diagnosis of alcohol use. Review of the physician ordered Plan of Care (POC) for certification period 3/6/26 through 5/4/26, indicated the following: *Home Health Aide (HHA) visits 2 times a week x 2 weeks Review of the clinical record indicated the following HHA visit notes that were signed/dated after the visit: *3/11/26 visit, note completed on 3/18/26 *3/13/26 visit, note completed on 3/17/26 *3/26/26 visit, note completed on 3/30/26 During an interview on 4/2/26 at 2:42 P.M., the Director, after reviewing the clinical record, said the HHA visit notes had not been completed and submitted within the required timeframe.”

“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 interview, the agency failed to ensure that the physician ordered plan of care was followed for five Patients (#2, #6, #9, #3, and #10), out of 17 sampled patients. 4. Patient #3 was admitted to the agency in February 2026 with a diagnosis of surgical aftercare digestive system and required skilled services. Review of the physician ordered POC for certification period 2/15/26 through 4/15/26 indicated the following: *HHA visits twice weekly x 8 weeks (2/15/26 through 4/11/26) Review of the clinical record indicated no documented evidence HHA visits were provided the weeks of 2/15/26 through 2/21/26 and 2/22/26 through 2/28/26. During an interview on 4/3/26 at 10:18 A.M., the Director, after reviewing the clinical record, said the HHA visits were not provided to Patient #3 per the physicians ordered Plan of Care as required. 5. Patient # 4 was admitted to the agency in December 2024 with a diagnosis of atrial fibrillation and required skilled care. Review of the physician ordered POC for certification period 2/5/26 through 4/5/26 indicated the following: *HHA visits twice weekly x 8 weeks (2/5/26 through 3/28/26) Review of the clinical record indicated no documented evidence HHA visits were provided the week of 2/22/26 through 2/28/26. During an interview on 4/2/26 at 3:10P.M., the Director, after reviewing the clinical record, said HHA visits were not provided to Patient #4 per the physicians ordered Plan of Care as required. Findings include: Review of the agency’s policy titled Missed Visit Documentation Procedure, dated October 2025, indicated but was not limited to the following: *A visit is considered missed when: - A scheduled visit is not performed as ordered on the physician-approved plan of care. - This includes patient refusal, inability to reach patient, clinician issue, or external factors (e.g., hospitalization). *If missed visit is a HHA (Home Health Aide) visit, HHA must contact case manager or clinical manager for notification of missed visit. Case manager or Clinical manager to follow up with MD notification of missed visit. *The clinician must enter a Missed Visit Note in the EMR (electronic medical record) including: - Date of scheduled visit - Discipline (RN, LPN, PT, OT, etc.) - Reason for missed visit - All contact attempts - Patient/caregiver response - Clinical status - Plan for follow-up/rescheduling 1. Patient #2 was admitted to the agency in January 2026 with a diagnosis of hypertensive heart and kidney disease with heart failure. Review of the physician ordered Plan of Care (POC) for certification period 1/31/26 through 3/31/26, indicated the following: *HHA visits once a week x 9 weeks (2/1/26 to 3/31/26) Review of the clinical record indicated no documented evidence that an HHA visit was provided the weeks of 2/15/26 through 2/21/26 and 2/22/26 through 2/28/26. 2. Patient #6 was admitted to the agency in March 2026 with diagnosis of hemiplegia (severe, often permanent form of paralysis affecting one side of the body due to brain or spinal cord injury)/hemiparesis (often temporary, muscle weakness affecting one side of the body) status post Cerebrovascular Accident (CVA). Review of the physician ordered POC for certification period 3/14/26 through 5/12/26, indicated the following: -HHA visits 2 times a week x 8 weeks (3/15/26 to 5/9/26) Review of the clinical record indicated no documented evidence that a second HHA visit was provided the week of 3/15/26 through 3/21/26. 3. Patient #9 was admitted to the agency in March 2026 with a diagnosis of alcohol use. Review of the physician ordered POC for certification period 3/6/26 through 5/4/26, indicated the following: -HHA visits 2 times a week x 2 weeks (3/8/26 to 3/21/26) Review of the clinical record indicated no documented evidence that a second HHA visit was provided the week of 3/15/26 through 3/21/26. During an interview on 4/2/26 at 2:42 P.M., the Director, after reviewing the clinical records, said HHA visits were not provided to Patients’ #2, #6, and #9 per the physicians ordered Plan of Care 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) for 1 patient (#4) out of 17 sampled patients. Findings include: Review of the agency’s policy titled Home Health Supervision Procedure: LPN, dated 10/1/25, included but was not limited to the following: *All Licensed Practical Nurses (LPN) must be supervised by a RN. *The RN is responsible for overall patient management, clinical oversight, care planning and evaluation. *The RN must conduct a supervisory visit at least every 30 days. *The RN must document the date of the supervisory visit. Patient #4 was admitted to the agency in February 2026 with a diagnosis of chronic obstructive pulmonary disease (COPD- prevents airflow to the lungs, causing breathing problems) and required skilled home care services Review of the physician ordered Plan of Care (POC) for certification period 2/7/26 through 4/7/26, indicated the following: *Skilled Nursing (SN) visits: 2 visits every week x 1 week (2/8/26 to 2/14/26). *SN visits: 1 visit every week x 8 weeks (2/25/26 to 4/7/26). *SN visits: 3 visits as needed (2/7/26 to 4/7/26) Review for the clinical record for dates of services between 2/7/26 through 4/1/26 indicated LPN visits were conducted on 2/12/26, 2/26/26, 3/5/26, 3/9/26 and 3/25/26. Further review of these dates of service failed to include any documented RN supervisory visits. During an interview on 4/3/26 at 10:11 A.M., the Director, after reviewing the clinical record, said the RN should have provided and documented supervision of the LPN every 30 days per regulation.”

“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 (#4), out of 17 sampled patients. Finding include: Review of the agency’s policy titled Home Health Supervision Procedure: Home Health Aide, dated 10/1/25, indicated but was not limited to the following: *All HHAs are supervised in accordance with federal and Massachusetts regulations. Supervisory visits are completed to ensure safe, appropriate care and adherence to the plan of care. *A supervisory visit must be completed at least every 14 days. *Applies to all patients receiving HHA services. *Registered Nurse (RN) can perform the visit or the therapist (PT/OT/SLP) if they are the primary clinician managing the case. *Licensed Practical Nurses (LPNs) may not perform the supervisory visits. *Each supervisory visit must include date of visit, clinician name and credentials. Patient #4 was admitted to the agency in February 2026 with a diagnosis of chronic obstructive pulmonary disease (COPD- prevents airflow to the lungs, causing breathing problems) and required skilled home care services. Review of the physician ordered Plan of Care (POC) for certification period 2/7/26 through 4/7/26, indicated the following: *HHA visits: 2 visits every 8 days for 8 days (2/7/26 to 2/14/26) *HHA visits: 2 visits every week x 5 weeks (3/1/26 to 4/4/26) Review of the clinical record for dates of service between 2/7/26 to 2/14/26 and 3/1/26 to 4/4/26 indicated HHA visits were conducted on 2/13/26, 3/4/26, 3/5/26, 3/11/26, 3/13/26, 3/16/26, 3/20/26, 3/23/26 and 3/27/26. Further review of these dates of service failed to include any supervisory visits for the HHA services. During an interview on 4/3/26 at 10:11 A.M., the Director, after reviewing the clinical record, 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.”