VNA of Maryland- Easton

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on the medical record review, the agency’s staff failed to complete the patient’s visit frequencies as ordered in the plan of care. The missed visit was also undocumented. Missed visits placed the patient at risk of not meeting outcome goals and delays in treatment and care. Patient #8 Findings include: On 8/21/2024, a medical record review for Patient #8 revealed, the skilled nurse (SN) missed a visit during week #2 of the patient care. The ordered frequency in the plan of care is 1 a week for 3 weeks. There is no documentary evidence related to why the visit was missed or if the patient’s physician was notified of the missed visit.”

“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 during a patient’s home visit, the agency’s nursing professional failed to comply with infection control and prevention standards during the care provided to the patient. Not following standard infection control practices causes potential contamination (spread of bacteria) to the patient’s wound and living environment. Home visit #1 Findings included: During home visit #1, the observation revealed the skilled nursing professional did not use a barrier large enough to place the patient’s entire foot while completing an assessment of the foot and providing wound care. The skilled professional placed a 4X4 gauze under the heel of the foot, which left the remainder of the foot to have contact with the bare flooring in the patient’s home.”

“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 a medical record review, the agency’s skilled nurse failed to complete an assessment of the patient within 48 hours of receipt of the patient’s referral for 2 out of 10 patients reviewed. Not completing the assessment has the potential to cause a delay in care and the potential to cause adverse health outcomes for the patient. Patient #1, #6 Findings include: 1. On 8/19/2024, a medical record review for Patient #1 revealed a referral date of 7/24/24. The patient’s start of care (SOC) occurred on 07/30/24. There was no documentary evidence to explain the delay. There was no hospital discharge note in the record. The agency’s administrative staff was unable to explain the delay. 2. On 08/19/2024, a review of Patient #6’s medical record revealed the referral of 5/17/2024. The patient’s (SOC) occurred on 5/21/2024. There was no documentary evidence to support that the physician ordered a change to the SOC or that the patient requested a change.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on a medical record review, the agency’s staff failed to follow the physician’s orders. Not following a physician’s orders causes a delay in care and the potential to cause adverse health outcomes for the patient. Patient #1 Findings include: Patient #1’s physician ordered skilled nurse frequency, which was not followed as ordered by the physician and did not include a documented reason. The ordered frequency was 3 times a week for 1 week, 2 times a week for 5 weeks, and 1 time a week for 3 weeks. During week 1, the patient had 1 visit (the agency did not provide 2 visits), and during week 2, the patient had 1 visit (the agency did not provide 1 visit).”