Nightingale Visiting Nurses

“EP Training and Testing CFR(s): 484.102(d) §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: Based on record review and staff interview, the agency failed to implement an emergency preparedness training program for new employee orientation and annually thereafter, based on an emergency plan for four (Certified Occupational Therapy Assistant [COTA}#1, Home Health Aide [HHA] #1, Licensed Practical Nurse [LPN] #1, and Physical Therapist [PT] #1,) of four employees reviewed. Findings Include: Review of the agency policy for Emergency Preparedness, titled Standard HH7-3A.01, Standard HH7-3B.01, and Standard HH7-3C.01, undated, included the following: *The Agency educates all personnel about the process to meet patient needs in a disaster or crisis situation. *Staff receive training about the company’s Emergency Management Plan, including their roles and responsibilities during orientation and at least annually or more often if changes/updates to the plan are implemented. Review of employee training for Emergency Preparedness indicated the following: *No documented evidence that emergency preparedness training was completed for COTA #1 upon hire or annually thereafter. *No documented evidence that emergency preparedness training was completed for HHA #1 upon hire or annually thereafter. *No documented evidence that emergency preparedness training was completed for LPN #1 upon hire or annually thereafter. *No documented evidence that emergency preparedness training was completed for PT #1 upon hire or annually thereafter. During an interview on 2/29/26 at 4:30 P.M., the Clinic Manager said that she was unable to provide emergency preparedness training for staff.”

“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 that all entries were legible, clear, complete, and appropriately authenticated, dated, and timed for 3 patients (#1, #7, and #5), out of total sample of 17 patients. Findings include: 3. Patient #5 was admitted to the agency in October 2025 with a diagnosis of a femur fracture. Review of the clinical record indicated the nurse obtained verbal orders for the Home Health Certification and POC, dated 12/26/25-2/23/26, on 12/23/26. Further review of the clinical record indicated the Home Health and POC, dated 12/26/23 through 2/23/26, was not signed by the physician until 2/3/26, beyond the 30-day requirement. During an interview on 2/29/26 at 4:43 P.M., the Clinical Manager said the physician order was not signed within 30 days, as required, after staff obtained the verbal order. Review of the agency’s policy entitled, Confirmation of Verbal Orders, revised 6/24/25, indicated the following: *Verbal/telephone orders are signed by the physician within 30 days of receipt of the orders by agency personnel. 1. Patient #1 was admitted to the agency in December 2025 with a diagnosis of a two-part displaced fracture of the right humerus (the single long bone in the upper arm). Review of the clinical record indicated the nurse obtained verbal orders for the Home Health Certification and Plan of Care (POC), dated 12/22/25 through 2/19/26, on 12/22/25. Further review of the clinical record indicated the Home Health and POC, dated 12/22/25 through 2/19/26, was not signed by the physician until 1/27/26, beyond the 30-day requirement. During an interview on 2/19/26 at 10:30 A.M., the Clinic Manager said the physician order was not signed within 30 days, as required, after staff obtained the verbal order. 2. Patient #7 was admitted to the agency in November 2025 with a diagnosis of an encounter for orthopedic aftercare. Review of the clinical record indicated the nurse obtained verbal orders for the Home Health Certification and POC, dated 11/3/25 through 1/1/26, on 11/3/25. Further review of the clinical record indicated the Home Health and POC, dated 11/3/25 through 1/1/26, was not signed by the physician until 12/5/26, beyond the 30-day requirement. During an interview on 2/19/26 at 10:30 A.M., the Administrator said the physician order was not signed within 30 days, as required, after staff obtained the verbal order.”

“Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to provide proper written notice, in advance of the HHA reducing or terminating on-going care, for 2 patients (#6 and #7), out of a total sample of 17 patients. Findings include: Review of the agency’s policy entitled, Standard HH5-6A, HH5-7A, undated, indicated the following: *For a Predictable Discharge: Specific discharge plans should be discussed with the patient/family at least one week prior to the expected discharge date. A Notice of Medicare Non-Coverage (NOMNC) should be completed at least 48 hours prior to discharge. 1. Patient #6 was admitted to the agency in July 2025 with a diagnosis of displaced fracture of the right less toe. Review of the physician ordered Home Health Certification and Plan of Care (POC), dated 9/28/25 through 11/26/25, indicated the following: -Physical Therapy (PT) visit: 2 times a week for 9 weeks. Review of a Physical Therapy Assistant (PTA) note, dated 11/25/26, indicated the patient would be discharged on the next visit, and however the note did not indicate the patient was issued a NOMNC. Further review of the clinical record indicated the patient was discharged from the agency on 11/26/25. During an interview on 2/19/26 at 4:40 P.M., the Clinic Manager said a NOMNC was not provided to the patient at least 48 hours prior to discharge, as required. 2. Patient #7 was admitted to the agency in November 2025 with a diagnosis of an encounter for orthopedic aftercare. Review of the physician ordered Home Health Certification and Plan of Care (POC), dated 11/3/25 through 1/1/26, indicated the following: -Effective 11/9/25 through 12/6/25, PT visit: 2 times a week for 4 weeks. Review of a missed visit PTA note, dated 11/27/25, indicated the patient did not want the visit and requested to be discharged because he/she would be starting outpatient therapy on 12/4/25. Further review of the clinical record indicated the patient was discharged from the agency on 12/3/25 and a NOMNC was issued on this same day. During an interview on 2/19/26 at 10:15 A.M., the Clinic Manager said staff could have verbally issued the NOMNC 48 hours prior discharge when he/she requested to be discharged and not waited until the discharge visit on 12/3/25. She said the NOMNC was not provided 48 hours prior to discharge, as required.”

“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, policy review, and interview, the agency failed to ensure that the initial assessment visit was 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, for 3 patients (#1, #6 and #7), out of a total sample of 17 patient. Findings include: Review of the agency’s policy entitled, Standard HH5-2A, HH5-2B, HH5-2C, HH5-2C.01, HH5-2D, HH5-2E, HH5-5A, revised 11/11/06, indicated the following: *The initial diagnosis and age-appropriate assessment shall be performed by a registered nurse, or therapist if physician orders therapy only, within 48 hours of the time of the referral, within 48 hours of the patient’s return home, or at the physician start of care dated. 1. Patient #1 was admitted to the agency in December 2025 with a diagnosis of a two-part displace fracture of the right humerus (the single long bone in the upper arm). Review of the clinical record indicated the physician sent a referral on 11/27/25, and then sent updated clinical information required by the agency on 12/10/25. Further review of the clinical record indicated the initial assessment was completed on 12/22/25, 12 days after the final clinical information was provided by the physician. The record did not contain any documentation related to the delay in completing the initial assessment and not completing it within 48 hours of the referral. Additionally, there was not any documentation that a new order for the start of care date was obtained from the physician. During an interview on 2/19/26 at 10:30 A.M., the Clinic Manager said staff should have obtained a physician order to perform the initial assessment if they could not perform it within 48 hours of the referral. She said the initial assessment was not performed within 48 hours of the referral, as required. 2. Patient #6 was admitted to the agency in July 2025 with a diagnosis of displaced fracture of the right less toe. Review of the clinical record indicated the agency received a referral from the physician on 7/24/25. Further review of the clinical record indicated the initial assessment was completed on 7/30/25, 6 days after the referral. The record did not contain any documentation related to the delay in completing the initial assessment and not completing it within 48 hours of the referral. Additionally, there was not any documentation that a new order for the start of care date was obtained from the physician. During an interview on 2/19/26 at 4:40 P.M., the clinic Manager said staff did not document any reason why there was a delay for the initial start of care assessment. She said the initial assessment was not performed within 48 hours of the referral, as required, and there was not a new physician order to delay the initial assessment. 3. Patient #8 was admitted to the agency in August 2025 with a diagnosis autoimmune thyroiditis (an autoimmune condition of the thyroid gland [a gland located beneath the larynx], caused by the formation of antibodies that attack the thyroid gland, and it usually causes hypothyroidism [too little thyroid hormone]). Review of the clinical record indicated the physician sent a referral on 8/11/25 by the physician. Further review of the clinical record indicated the initial assessment was completed on 8/15/25, 4 days after the referral. The record did not contain any documentation related to the delay in completing the initial assessment and not completing it within 48 hours of the referral. Additionally, there was not any documentation that a new order for the start of care date was obtained from the physician. During an interview on 2/19/26 at 5:00 P.M., the Clinic Manager said staff should have completed the initial assessment within 48 hours of the referral, as required.”

“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 record review, policy review and interview, the agency failed to ensure a completed discharge summary was 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 home health agency (HHA) within 5 business days of the patient’s discharge, for 5 patients (#6, #7, #8, #9, and #5), out of total sample of 17 patients. Findings include: 5. Patient #5 was admitted to the agency in October 2025 with a diagnosis of a femur fracture. Review of the physician ordered Home Health Certification and POC, dated 12/26/25 through 2/5/26, indicated the following: -Effective 12/26/25 through 1/3/26, PT visit: 1 visit per week for 1 week -Effective 1/4/26 through 2/7/26, PT visit: 2 visits per week for 5 weeks -Effective 12/28/25 through 1/10/26, OT visit: 1 visit per week for 2 weeks Review of the clinical record indicated the patient was discharged from the agency on 2/5/26, and the OT completed the discharge summary on this day. Further review of the clinical record indicated the discharge summary was sent to the physician on 2/13/26, 8 days after discharge. During an interview on 2/19/26 at 4:40 P.M., the Clinic Manager said the discharge summary was not sent to the physician within 5 days of discharge, as required. Review of the agency’s policy entitled, Standard HH5-6A, HH5-7A, undated, indicated the following: *A copy of the discharge summary is sent to the primary care physician and/or referral source within 5 days of discharge. 1. Patient #6 was admitted to the agency in July 2025 with a diagnosis of displaced fracture of the right less toe. Review of the physician ordered Home Health Certification and Plan of Care (POC), dated 9/28/25 through 11/26/25, indicated the following: -Physical Therapy (PT) visit: 2 times a week for 9 weeks. Review of a Physical Therapy Assistant (PTA) note, dated 11/25/26, indicated the patient would be discharged on the next visit. Review of the clinical record indicated the patient was discharged from the agency on 11/26/25, and the Physical Therapist completed a discharge summary on this day. Further review of the clinical record indicated the discharge was sent to the physician on 12/1/25, 6 days after discharge. During an interview on 2/19/26 at 4:40 P.M., the Clinical Manager said the discharge summary was not sent to the physician within 5 days of discharge as required. 2. Patient #7 was admitted to the agency in November 2025 with a diagnosis of an encounter for orthopedic aftercare. Review of the physician ordered Home Health Certification and POC, dated 11/3/25 through 1/1/26, indicated the following: -Effective 11/9/25 through 12/6/25, PT visit: 2 times a week for 4 weeks. Review of the clinical record indicated the patient was discharged from the agency on 12/3/25, and the nurse completed a discharge summary on this day. Further review of the clinical record indicated the discharge summary was sent to the physician on 12/11/25, 9 days after discharge. During an interview on 2/19/26 at 4:40 P.M., the Clinical Manager said the discharge summary was not sent to the physician within 5 days of discharge, as required. 3. Patient #8 was admitted to the agency in August 2025 with a diagnosis autoimmune thyroiditis (an autoimmune condition of the thyroid gland [a gland located beneath the larynx], caused by the formation of antibodies that attack the thyroid gland, and it usually causes hypothyroidism [too little thyroid hormone]). Review of the physician ordered Home Health Certification and POC, dated 10/14/25 through 12/12/25, indicated the following: -Effective 11/23/25 through 12/12/25, PT visit: once a week for 3 weeks. Review of the clinical record indicated the patient was discharged from the agency on 12/12/25, and the Physical Therapist completed a discharge summary on this day. Further review of the clinical record indicated the discharge summary was sent to the physician on 12/23/25, 12 days after discharge. During an interview on 2/19/26 at 2:40 P.M., the Clinical Manager said the discharge summary was not sent to the physician within 5 days of discharge, as required. 4. Patient #9 was admitted to the agency in October 2025 with a diagnosis of aftercare following joint replacement surgery. Review of the physician ordered Home Health Certification and POC, dated 10/20/25 through 12/18/25, indicated the following: -Effective 11/23/25 through 12/10/25, Occupational Therapy (OT) visit: once a week for 4 weeks. Review of the clinical record indicated the patient was discharged from the agency on 12/16/25, and the Occupational Therapist completed a discharge summary on this day. Further review of the clinical record indicated the discharge summary was sent to the physician on 2/5/25, 50 days after discharge. During an interview on 2/19/26 at 5:15 P.M., the Clinical Manager said the discharge summary was not sent to the physician within 5 days of discharge, as required.”