All Care VNA-Greater Lynn Inc.

“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, interview and policy review, the agency failed to ensure that 1 staff member (Registered Nurse [RN] #1) implemented adequate infection control measures to reduce the risk of transmission of infection. Specifically RN #1 failed to 1.) follow the agency infection control policy related to bag technique; 2.) follow the agency policy related to wound dressing change policy, during observations of 1 of 7 home visits. Findings include: Review of the agency policy, titled, Bag Technique, last updated 9/12, included the following: The purpose of bag technique is to reduce the risk of cross-infection between patients via the visit bag and the supplies it contains. Placing the bag in a “clean” area of the home: Appropriate areas include placing on a clean hard surface or a paper towel or hanging on the back of a chair or doorknob. Bag technique requires keeping the inside of the bag and all its contents “clean”. Only enter clean part of the bag with clean hands (perform hand hygiene immediately prior to entering/re-entering bag). If a laptop computer or other electronic devices are part of the equipment carried in the visit bag, apply the principles of bag technique to the devices. Review of the agency policy, titled, Skin and Wound Care - Basic Wound Care: Dressing Application, last updated 9/12, included the following: Establish a clean field with all the supplies and equipment that will be necessary. Remove soiled dressing. Discard dressing and gloves in appropriate containers. Decontaminate hands and don clean gloves. Cleanse wound per wound care orders. Dress wound with appropriate dressing following physician orders. 1.) RN #1 failed to follow the agency policy related to bag technique. On 9/4/25 at 11:30 A.M., the surveyor observed RN #1 perform a home visit for Patient #6. RN #1 placed her bag down on a clean field but placed her laptop next to the field on the patients coffee table without first cleaning the surface. During the visit RN #1 noted that both knees of Patient #6 were bleeding. She donned gloves and placed a bandaid to both knees. She removed her gloves, keeping them in the palm of her left hand she began using the keyboard to document the visit. During an interview on 9/4/25 at 12:26 P.M., RN #1 said that because it is a clean home she felt comfortable placing the laptop down on the table, she said she would have used a field if she didn’t think it was clean. She said she should have performed hand hygiene after removing her gloves. During an interview on 9/4/25 at 1:30 P.M., the Vice President of Clinical Services said that a laptop should be placed on a solid surface that the clinician has cleaned or on a field. She also said that a clinician should perform hand hygiene after removing gloves and should not use the laptop while holding contaminated gloves. 2.) RN #1 failed to follow the agency policy related to wound dressing changes. On 9/4/25 at 11:30 A.M., the surveyor observed RN #1 perform a home visit for Patient #6. During the visit RN #1 removed a dressing from the patients upper right arm. The surveyor observed a scant amount of dark dried drainage on the dressing. RN #1 discarded the dressing and proceeded with cleanse and cover the wound without removing her gloves, performing hand hygiene and donning new gloves. During an interview on 9/4/25 at 12:26 P.M., RN #1 said that she did not change her gloves because the dressing was dry. She said she would have changed her gloves if there wet drainage on the dressing. During an interview on 9/4/25 at 1:30 P.M., the Vice President of Clinical Services said that after removing a dressing a clinician should remove their gloves, perform hand hygiene and don new gloves.”

“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 interview and document review, the Home Health Agency (HHA) failed to communicate with the physician when services were not provided as ordered for 2 patients (#11, #15), out of a total sample of 17 patients. Findings include: Findings include: Review of the HHA policy titled Communication with the Physician (dated 3/6/25) included but was not limited to the following: To ensure ongoing communication between the HHA and the patient’s physician (s) as appropriate to the scope of care and services. The physician is notified in writing a minimum of every 60 days and as needed. Physicians will be notified in the interim but not limited to: -Changes in the POC -When there is any problem implementing the POC 1. Patient #11 was admitted to the agency in June 2025 with a diagnosis of knee pain and was discharged from the agency in August 2025. Review of the Home Health Certification and Plan of Care for certification period 6/30/25 to 8/28/25 indicated the following: *Skilled Nursing (SN) 1 time a week for 9 weeks and 3 as needed (prn) visits *Physical Therapy (PT) 1 time a week for 9 weeks. Review of the clinical record indicated that the following missed visits with no physician notification as required: -For the week of 7/13/25 - 7/19/25, skilled nursing was not provided as ordered due to the patient not home, and there is no indication that physician was notified. -For the week of 7/27/25 - 8/2/25, physical therapy was not provided as ordered due to patient/family refused, and there is no indication that physician was notified. -For the week of 8/3/25 – 8/9/25, physical therapy was not provided as ordered due to patient/family refused, and there is no indication that physician was notified. -For the week of 8/10/25 – 8/16/25, physical therapy was not provided as ordered due to patient/family refused, and there is no indication that physician was notified. 2. Patient # 15 was admitted to the Agency July 2025 with a diagnosis of Atherosclerotic Heart disease with recent Coronary Artery Bypass Graft (CABG) surgery. Review of the Home Health Certification and Plan of Care for certification period 7/15/25 through 9/12/25 indicated the following: *Skilled Nursing (SN) 2 times a week for 2 weeks; 1 time a week for 7 weeks and 3 as needed (prn) visits *Physical Therapy (PT) 1 time a week for 9 weeks. *Occupational Therapy (OT) 2 times a week for 3 weeks; 1 time a week for 6 weeks. *Home Health Aide (HHA) 1 to 2 times a week for 9 weeks. Review of the clinical record indicated that the following missed visits with no physician notification as required: -For the week of 7/20/25 - 7/26/25, skilled nursing was not provided as ordered due to conflict in schedule, and there is no indication that physician was notified. -For the week of 8/10/25 - 8/16/25, skilled nursing was not provided as ordered due to conflict in schedule, and there is no indication that physician was notified. During an interview on 9/4/25 at 3:15 P.M. the Vice President of Operations confirmed the lack of documentation of physician notification and said that the physician should be notified when services were not provided as ordered.”

“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 (#16), out of a total sample of 17 patients. Findings include: Review of the agency’s policy entitled “Care Planning Process”, revised August 2020, indicated the following: *For clients requiring a Home Health Aide (HHA), an HHA Care Plan is developed. The qualified discipline will complete the Home Health Supervision visit every two weeks. Patient # 16 was admitted to the agency in July 2025 with a diagnosis of osteoarthritis, right shoulder and required skilled home care services. Review of the physician order Home Health Certification and Plan of Care, dated 7/10/25 through 9/7/25, indicated the following: *HHA visits (HHAVs): 1-2 days a week, times 9 weeks to assist with showers. Review of the clinical record indicated that patient #16 received home health aide visits 2 times a week from 7/21/25 through 9/1/25. The only home health aide supervisory visit was on 8/16/25, not every 14 days as required. During an interview on 9/5/25 at 12:10 P.M., the Director of Quality Improvement said that she reviewed patient #16’s medical record and the only supervisory visit for home health aide she found was on 8/16/25. She said that supervisory visits for home health aide should be conducted every 14 days.”

“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 document review and interview, the agency failed to ensure that a discharge summary was sent to the primary care physician within 5 business days of the patients discharge for 2 of 5 discharge records reviewed (#8, #12), out of a total sample of 17 patients. Findings include: b. Patient #12 was admitted to the agency in June 2025 with a diagnosis of heart failure. Review of the medical record indicated that Patient #12 was discharged from the agency on 8/4/25, but the discharge summary was not sent to the physician. During an interview on 9/4/25 at 2:45 P.M., Vice President of Operations said that discharge summaries should be sent within 5 business days. Review of the agency policy, titled, Sending Discharge Summaries to Attending MD’s, updated 4/7/25, included the following: 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 (Home Health Agency) within 5 business days of the patient’s discharge. a. Patient #8 was admitted to the agency in March 2025 with a diagnosis of rib fracture. Review of the medical record indicated that Patient #8 was discharged from the agency on 3/27/25, but the discharge summary was not sent to the physician until 4/4/25, 6 business days after discharge.”