Nightingale Home Health of Nevada

“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 document review, interview, and policy review, the Home Health Agency (HHA) failed to ensure two of nine patients (Patient (P) 2 and P4) received services as ordered by the physician as identified in the Plan of Care (POC). This failure had the potential to result in a decline in patients’ health status. Findings include: Review of the agency’s undated policy titled, “Standard HH5-4A, Standard HH5-8A, Standard HH5-8B,” revealed, “All clinical services are implemented only in accordance with a plan of care established by a physician’s written order … Agency staff shall promptly inform the physician of any changes that suggest a need to alter the patient’s Plan of Care and to obtain verbal authorization for same.” 1. Review of P2’s referral information, dated 04/15/25, located in the electronic medical record (EMR) under the “Misc” tab, revealed Skilled Nursing (SN) home health visits ordered by the physician for wound care. Review of P2’s POC located in the EMR under the “Orders” tab for certification period 04/22/25 to 06/20/25, revealed SN visits ordered once a week for five weeks. Review of P2’s SN visit documentation located in the EMR under the “Nursing” tab revealed a SN visit occurred on 04/22/25 for the Start of Care (SOC) comprehensive assessment and that no other SN visit occurred until 06/04/25 which was six weeks after the SOC. Review of P2’s physician orders located in the EMR under the “Orders” tab revealed there was no documentation to show the physician was notified of the change in SN visit frequency or an updated order obtained until 06/04/25. 2. Review of P4’s referral information, dated 04/04/25, located in the EMR under the “Misc” tab, revealed home health SN ordered for IV [intravenous] ABX [antibiotics], weekly labs … discontinue PICC [peripherally inserted central catheter] line on completion of treatment … medication reconciliation … 3-5 ml [milliliter] flush pre/post med admin [administration], 5-10 ml NS [normal saline] flush for labs, 3 ml heparin [used to prevent blood clots] 10 units/ml flush after last NS flush or q [every] 12h [hours] if not in use.” Review of P4’s POC located in the EMR under the “Orders” tab for certification period 04/07/25 to 06/05/25, revealed from 04/07/25 to 05/03/25, SN visits ordered six visits per week for four weeks for wound care and IV medication administration. Review of P4’s SN visit documentation located in the EMR under the “Nursing” tab revealed SN visits were completed on 04/07/25, 04/08/25, 04/09/25, and 04/10/25. No visits are documented for the next two weeks. P4 was then seen on 05/02/25, 05/07/25, 05/09/25, 05/16/25, 05/19/25, 05/27/25, and 05/30/25. Review of P2’s physician order located in the EMR under the “Orders” tab revealed an order for change of frequency for SN two times a week for two weeks written by the Regional Director of Clinical Services on 05/21/25. The EMR did not include notification of the physician regarding the missed visits related to the POC order for SN six visits for four weeks. During an interview on 06/11/25 at 11:15 AM, the Regional Director of Clinical Services revealed the above missed visits occurred when the former Director of Clinical Services was responsible for completing patient admissions and doing SN visits. The Regional Director of Clinical Services confirmed there was no documentation for the visits being completed or physician notification of missed visits.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on document review and interviews, the Home Health Agency (HHA) failed to provide the name of the Administrator for one of one patient (Patient (P) 2) reviewed during a home visit observation. This failure had the potential to deter the patient or caregiver from verbalizing a complaint or concern due to the lack of direct contact information. Findings include: Review of the HHA’s provided policies failed to identify the requirement to provide patients with the name of the Administrator. Review of documentation included in the home health information provided to P2 during a home visit observation on 06/10/25 at 1:30 PM, revealed the name of the Administrator was not included in the information provided to the patient/caregiver. The document revealed to call the “Administrator” and provided a phone number that went to a central corporate answering system in another state who screened the calls and then would forward the caller to the appropriate person. During an interview on 06/11/25 at 10:30 AM, the Director of Clinical Services stated, “The nurse is supposed to fill in the name of the Administrator [on the line indicated in the admission information provided to the patient].””

“Make complaints to the HHA CFR(s): 484.50(c)(3) Make complaints to the HHA regarding treatment or care that is (or fails to be) furnished, and the lack of respect for property and/or person by anyone who is furnishing services on behalf of the HHA; This Element is not met as evidenced by: Based on document review and staff interview, the Home Health Agency (HHA) failed to receive and document a patient grievance regarding the care for a one of nine sample patients (Patient (P) 6) he HHA’s failure to recognize, document and respond to the patient’s grievance places all patients at risk of presenting the HHA with a grievance and the HHA’s failure to respond to that grievance. Findings include Review of the HHA’s undated policy titled, “STANDARD HH2-4A, STANDARD HH2-4A. OI, STANDARD HH2-4A,02, STANDARD IdH2-48” directed “The agency investigates, documents and resolves all patient grievances/complaints and documents the results in a timely manner.” The purpose of the policy was “To support and respect patient’s’ rights to have concerns/grievances about their care and/or services heard, reviewed, and if possible, resolved thereby promoting positive outcomes.” The Procedure directed the complaint investigation shall begin within 48 hours of receipt of the written complaint written by the staff member who received the complaint. The Director of Patient Care Services and/or Administrator and/or Designed will notify the patient/family/caregiver within five (5) days of receipt of the complaint and the patient/family/caregiver will be notified in writing within 14 days of the results of the investigation and the Agency’s response. Review of P6’s electronic medical record (EMR) revealed an admission date of 04/24/23 and 13 consecutive recertification periods. On 03/21/25, P6, family and/or representative verbalized to the former Director of Clinical Services their dissatisfaction with the HHA’s skilled nursing (SN) care and services and requested to discontinue the skilled nursing care services. During an interview on 06/10/25 at 10:10 AM the Director of Clinical Services stated P6 was on service with wound care/SN and Physical Therapy services and confirmed knowledge of the P6’s/family’s and/or representatives’ dissatisfaction with the SN care provided by the former Director of Clinical Services and requested the former Director of Clinical Services not return for SN visits. The Director of Clinical Services confirmed P6’s/family’s and/or representative’s grievance was not documented and the HHA failed to respond to P6/family and/or representatives.”

“Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This Element is not met as evidenced by: Based on document review, interview, and policy review, the Home Health Agency (HHA) failed to ensure patients received services as outlined in the Plan of Care (POC) for two of nine patients (Patient (P) 2 and P4). This failure infringed on the patient’s right to receive all care and services ordered by the physician and documented in the POC. Findings include: Review of the agency’s undated policy titled, “Standard HH5-4A, Standard HH5-8A, Standard HH5-8B” revealed “All personnel involved in the patient’s care are responsible for coordinating care effectively to support the objectives outlined in the patient’s plan of care …Purpose: …To assure that patient care needs are being address adequately and appropriately … All clinical services are implemented only in accordance with a plan of care established by a physician’s written orders.” 1. Review of P2’s referral information received by the HHA on 04/15/25 revealed a physician order for wound care which read, “Right lateral lower leg. Cleanse wound with Vashe wound solution. Apply hydrofiber [absorbent material that transforms into a gel on contact with wound fluid] dressing with silver (opticell ag) cover with bordered foam dressing. Change every 3 days and as needed if dressing is soiled or saturated with drainage.” Review of P2’s Outcome and Assessment Information Set (OASIS) Start of Care (SOC) Comprehensive Assessment located in the “Nursing” tab in the electronic medical record (EMR) revealed the SOC visit was completed on 04/22/25. Review of P2’s POC for Certification Period 04/22/25 to 06/20/25 revealed Skilled Nursing (SN) visits scheduled for “1 visit per week for 5 weeks.” Review P2’s of SN visit documentation located in the EMR under the “Nursing” tab revealed no SN visits were completed from 04/22/25 until 06/04/25. Review of P2’s “Missed Visit” documentation located in the EMR in the “Nursing” tab revealed the Regional Director of Clinical Services notified the primary care provider (PCP) that scheduled visits did not occur on 05/13/25, 05/19/25, and 05/26/25. The missed visit notification documentation revealed, “The visit was assigned to [STAFF NAME]. Unfortunately, it is not clear if [STAFF NAME] made this visit or not as [he/she] has failed to respond to attempts to reach out to [him/her] regarding past due documentation…” During a home visit interview on 06/10/25 at 1:30 PM, P2 confirmed that no SN visit occurred from 04/22/25 until 06/04/25 and that the wound dressing was not changed during that time. P2 further stated the agency was not contacted because there had been three deaths in the family during that time and P2 had been preoccupied. During an interview on 06/09/25 at 2:00 PM, the Director of Clinical Services confirmed that no SN visits were documented, and no wound care was provided for P2 between 04/22/25 and 06/04/25. The Director of Clinical Services stated, “the dressing has not been changed since 04/22/25.” The Director of Clinical Services stated the prior Director of Clinical Services was terminated the first week of June and had not completed P2’s SN visits or wound care. 2. Review of P4’s referral information dated 04/04/25 located in the EMR under the “Misc” tab revealed a physician order for “Home Health Care, IV [intravenous] …for 2 weeks; End date 04/20/25 ABX [antibiotic] PICC [peripherally inserted central catheter] line care Weekly labs for CBC [Complete Blood Count], CMP [Comprehensive Metabolic Panel], ESR [Erythrocyte Sedimentation Rate], CPK [Creatine Phosphokinase], CRP [C-reactive Protein]Please discontinue PICC line on completion of treatment … 3-5 ml [milliliters] NS [normal saline] flush pre/post med admin, 5-10 ml NS flush for labs, 3 ml heparin 10 units/ml after last NS flush or q12 h [every 12 hours] if not in use.” Review of P4’s POC located in the EMR under the “Orders” tab showed SN frequency of “6 visits per week for 4 weeks for weekly wound care and IV medication administration” starting on 04/07/25. Review of P4’s SN visit notes located in the EMR under the “Nursing” tab revealed SN visits were completed on 04/07/25, 04/08/25, 04/09/25, 04/10/25, 05/02/25, 05/07/25, 05/09/25, 05/16/25, 05/19/25, 05/27/25, 05/30/25, 06/02/25, and 06/04/25. This was not consistent with the frequency identified in the POC. Review of P4’s EMR under the “Orders” tab revealed that an order for change of frequency was written on 05/21/25 showing, “Eff [effective] week of 5/25 SN 2w2 [two times a week for two weeks].” The EMR did not include physician notification of missed visits or change in frequency prior to 05/21/25. Review of P4’s OASIS Comprehensive Assessment located in the EMR under the “Nursing” tab revealed in the section labeled “Skilled Intervention” Hold SN week of 04/13 to week of 4/27 per patient request as patient has help during those 2 weeks. Eff [effective] week of 4/27 SN 1w1, 2w1, 1w3 [one visit for one week, then two visits a week for one week, and then one visit a week for three weeks].” The EMR did not include documentation that the physician was notified. Review of P4’s SN visit notes located in the EMR under the “Nursing” tab failed to reveal PICC line care or lab work was completed during the visits. Review of P4’s POC located in the EMR under the “Orders” tab revealed physician ordered lab work and PICC line flushes were not included in the POC. During an interview on 06/10/25 at 10:00 AM, the Director of Clinical Services confirmed that PICC line care and orders for lab work were not included in the POC. The Director of Clinical Services confirmed that documentation was not present in the EMR to show that visits were completed according to physician orders. During an interview on 06/11/25 at 11:15 AM, the Regional Director of Clinical Services stated that the prior Director of Clinical Services was terminated the first week of June after he/she began not responding to emails, text messages, and phone calls. The Regional Director of Clinical Services also stated that as soon as they became aware of an issue the agency began looking for someone else to fill the role and hired the current Director of Clinical Services on 05/10/25.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on document review, interview, and policy review, the Home Health Agency (HHA) failed to include physician orders identified in the referral information in the individualized Plan of Care (POC) or include goals related to the specific physician orders for two of nine patients (Patient (P) 2 and P4). This failure had the potential to affect the quality of care and safety of patients. Findings include: Review of an agency’s undated policy titled, “Standard HH5-4A, Standard HH5-8A, Standard HH5-8B revealed, “When patients are referred to the Agency, the Agency will accept verbal physician orders communicated by a discharge planner, nurse practitioner, physician’s assistant, or other authorized staff members, to be followed by written, signed and dated physician orders in order to expedite the delivery of home health services … The initial plan of care must include the following items … Orders for the amount, frequency and duration of specific home health care services and disciplines, treatments, and procedures … Equipment and supplies needed … Patient goals and outcomes.” 1. Review of P2’s referral information, dated 04/15/25, located in the electronic medical record (EMR) under the “Misc” tab, revealed an order for home health Skilled Nursing (SN) for wound care written as “Right lateral lower leg. Cleanse with Vashe wound solution. Apply hydrofiber [absorbent material that transforms into a gel on contact with wound fluid] dressing with silver (opticell ag). Cover with silicone bordered foam dressing [a type of wound dressing]. Change every 3 days and as needed …” Review of P2’s POC with a Start of Care (SOC) date of 04/22/25, located in the EMR under the “Orders” tab, revealed the document did not include the orders for wound care, wound care supplies, or patient goals for wound healing. During an interview on 06/10/25 at 1:30 PM, P2 confirmed wound care, and a dressing change had not occurred since the SOC visit on 04/22/25. During an interview on 06/09/25 at 2:00 PM, the Director of Clinical Services confirmed P2 had a wound on admission and the wound was not identified in the SOC Comprehensive Assessment and orders for wound care were not included in the POC. 2. Review of P4’s referral information, dated 04/04/25, located in the EMR under the “Misc” tab, revealed physician orders included PICC line care. Weekly labs for CBC [Complete Blood Count], CMP [Comprehensive Metabolic Panel], ESR [Erythrocyte Sedimentation Rate], CPK [Creatine Phosphokinase], CRP [C-reactive Protein] … 3-5 ml [milliliter] NS [Normal Saline] flush pre/post med admin [administration], 5-10 ml NS flush for labs, 3ml heparin 10 units/ml flush after last NS flush or q [every] 12h [hours] if not in use. Review of P4’s POC with a SOC date of 04/07/25, revealed the document did not include the orders for PICC line care or lab work. During an interview on 06/09/25 at 4:05 PM, the Director of Clinical Services confirmed orders for PICC line care and lab work were not included in the POC.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on document review and interviews, the Home Health Agency (HHA) failed to provide a written schedule of visit frequency for one of one patient (Patient (P) 2) reviewed during a home visit observation. This failure had the potential to lead to missed patient visits due to conflict with other appointments. Findings include: Review of the HHA’s provided policies failed to identify the requirement to provide patients with a written schedule of visit frequency. Review of documentation included in the home health information provided to P2 during a home visit observation on 06/10/25 at 1:30 PM, revealed the patient was not provided with a written visit schedule or visit frequency. During an interview on 06/10/25 at 1:30 PM, P2 stated that he/she was not provided with a written schedule of visits or visit frequency. During an interview on 06/10/25 at 1:30 PM, the Director of Clinical Services confirmed that P2’s admission packet information did not include documentation of the frequency of services.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on document review and interviews, the Home Health Agency (HHA) failed to provide the patient or caregiver with a written schedule of medications for one of one patient (Patient (P) 2) reviewed during home visit observations. This failure had the potential to result in medication errors. Findings include: Review of the HHA’s provided policies failed to identify the requirement to provide patients with a written list of all medications. Review of the documentation included in the home health information booklet provided to P2 during observation on 06/10/25 at 1:30 PM, revealed the lack of a medication list including the name of the medication, dosage, and frequency. During an interview on 06/10/25 at 1:30 PM, P2 confirmed the lack of a medication list provided by the agency. During an interview on 06/10/25 at 1:30 PM, the Director of Clinical Services confirmed the expectation that the patient was provided with a medication list and stated, “A separate page is supposed to be completed by the admitting nurse and given to the patient.””

“Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This Element is not met as evidenced by: Based on document review and interviews, the Home Health Agency (HHA) failed to provide the patient or caregiver with the name of the Director of Clinical Services for one of one patient (Patient (P) 2) reviewed during home visit observations. This failure had the potential to deter the patient or caregiver from verbalizing a concern or contacting for a discussion of services due to the lack of direct contact information. Findings include: Review of the HHA’s provided policies failed to identify the requirement to provide patients with the name of the Director of Clinical Services. Review of the documentation included in the home health information booklet provided to P2 during observation on 06/10/25 at 1:30 PM, revealed the name of the Director of Clinical Services was not included in the information provided to the patient/caregiver. During an interview on 06/10/25 at 1:30 PM, P2 confirmed he/she was not informed of the name of the Director of Clinical Services. During an interview on 06/11/25 at 10:30 AM, the Director of Clinical Services stated, “The nurse is supposed to fill in the name [on the line indicated in the admission information provided to the patient].””