Visiting Nurses of Nevada, 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 review of the electronic medical record, staff interview, and review of home health agency (HHA) policies, it was determined the HHA’s software program did not include the correct time on entries of records for two of seven sampled patients (Patient(P)1 and 2). The potential to allow incorrect times of record entry had the potential to affect the 72 patients who were currently receiving HHA services and all future home health patients. Findings include: 1. Review of P1’s “Home Health Certification and Plan of Care,” located in the electronic medical record in the section titled “Plan of Care,” dated 06/02/2025, identified a “Start of Care,” dated 06/02/2025 with a certification timeframe of 06/02/2025 to 07/31/2025 and a primary diagnosis of chronic obstructive pulmonary disease. Orders for discipline and treatment were for the following: skilled nursing two times a week for two weeks and one time a week for seven weeks. Occupational Therapy and Physical Therapy to evaluate and treat. A review of P1’s June 2025 “Calendar,” located in the section of the electronic medical record titled “Calendar,” identified dates of services, physician orders, and care conferences. Occupational Therapy (OT) and Physical Therapy (PT) were scheduled on 06/04/2025 but documented as a “Missed Visit.” On review of the “Physical Therapy - Evaluation Note” and “Occupational Therapy – Evaluation Note” located on 06/04/2025 of the “Calendar” identified “Visit Date: 06/04/2025 From 8:00 to 9:00, Hours Spent: 1;” but the evaluation forms were not completed. During an interview with the Director of Patient Care Services (DPCS) on 07/07/2025 at 4:45 PM regarding the one hour of service on the “Evaluation Note,” it was revealed that PT and OT generate their visit when the agency notified them, and would write their time before the visit. The DPCS stated, “I have to correct that; the therapists were notified that the patient was going to the hospital. It means they scheduled the patient for that time. They forgot to delete it, or I do not know if they know how to delete it, or it could be a glitch in the software.” During an interview with the DPCS on 07/08/2025 at 9:15 AM, it was revealed the software program prefilled the document with the 8:00 AM time, before the visit. When staff visited the patient, the staff would change the time, clock in and clock out. During an interview with Registered Nurse (RN)2 on 07/08/2025 at 1:00 PM regarding no time was included on the progress notes. RN2 revealed the software company would be adding the time to “Physician Order” and visit notes. RN2 stated, “The computer program is supposed to prompt the time; it should be automatic; the policy will be updated to include time.” During a telephone interview with the Physical Therapist on 07/08/2025 at 3:52 PM regarding the “Physical Therapy – Evaluation Note” on “Visit Date: 06/04/2025, From: 8:00 to 9:00, Hours Spent:1” and the calendar identified “Missed Visit,” the PT revealed the following: there was no visit; the patient went to the hospital. The software program had an automatic time default to 8:00 AM - 9:00 AM. The PT would inform the intake coordinator the arrival and departure time of the patient visit. During a telephone interview with the Occupational Therapist on 07/08/2025 at 4:22 PM regarding the “Occupational Therapy – Evaluation Note” on “Visit Date: 06/04/2025, From: 8:00 to 9:00, Hours Spent:1,” and the “Calendar” identified “Missed Visit,” the OT stated, “there is a glitch in the system [software].” The OT would write a missed visit communication note. The OT did not input a time prior to the patient visit. The OT would input a time when the patient visit was completed, or the visit was attempted. 2. Review of P2’s “Home Health Certification and Plan of Care,” dated 05/17/2025, identified a Start of Care on 05/17/2025 with a certification timeframe of 05/17/2025 to 07/15/2025 and a primary diagnosis of atrial fibrillation, malignant neoplasm of colon, and kidney disease. The “Physician Order” was for skilled nursing one time a week for one week, two times a week for one week, and one time a week for seven weeks. Review of four of seven “Skilled Nursing - Progress Visit Note” completed by the Licensed Practical Nurse (LPN) did not include a time or date next to the electronic signature for visits on 05/19/2025, 05/23/2025, 06/11/2025 and 06/30/2025. The time was noted as “00.00.00.” The visit dates and times were as follows: - 05/19/2025 “Skilled Nursing - Progress Visit Note” was from 7:00 – 7:45 AM, Hours Spent: 0.75. - 05/23/2025 “Skilled Nursing - Progress Visit Note” was from 10:20-11:05 AM, Hours Spent: 0.75. - 06/11/2025 “Skilled Nursing - Progress Visit Note” was from 7:00 – 7:45 AM, Hours Spent: 0.75. - 06/30/2025 “Skilled Nursing - Progress Visit Note” was from 11:00 – 11:45 AM, Hours Spent: 0.75. During a telephone interview with the LPN on 07/08/2025 at 4:00 PM regarding the “Skilled Nursing – Progress Visit Note” that did not have a time next to the date of the LPN’s electronic signature, the LPN stated, “when I get to the patient, I change the time [from 8:00 to 9:00] and I clock in through the computer and clock out after the visit. Maybe there is a glitch in the system [software].” Review of the policy titled, “Services Provided,” dated 06/15/2023, identified “Services will be conducted by the Nursing Supervisor/Therapist in charge of the case. This will include...scheduling of visits, supervision of health team members and conferencing with health team members to plan and evaluate client care.” Review of the policy titled, “Delivery of Service,” dated 06/15/2023 included skilled nursing visit notes and therapy visit notes “shall be written on the date of service delivery and shall be submitted promptly to the agency so that they may be incorporated into the client’s clinical record within seven (7) working days from the time of service.” The agency could not provide a policy that addressed entry of time on delivery of services. On 07/09/2025 at 1:00 PM, the DPCS and RN2 confirmed that a “Missed Visit” should not have an arrival and departure time, and that the time was not available on the “Skilled Nursing – Progress Note Visit.””

“If concern identified, direct observation CFR(s): 484.80(h)(1)(ii) The supervisory assessment must be completed onsite (that is, an in person visit), or on the rare occasion by using two-way audio-video telecommunications technology that allows for real-time interaction between the registered nurse (or other appropriate skilled professional) and the patient, not to exceed 1 virtual supervisory assessment per patient in a 60-day episode. This Element is not met as evidenced by: Based on record review, interview, and policy review, the Home Health Agency (HHA) failed to complete an in-person on-site home health aide supervisory visit every 14 days for one of one patient (Patient (P) 4) reviewed for home health aide services out of a total sample of seven. This failure had the potential to result in unidentified patient or caregiver concerns or care not being provided as written in the home health aide care plan. Findings include: Review of the agency policy titled, “Home Health Aide Services/Supervision/Assignment,” dated 6/21/2024, revealed “The registered nurse shall perform the supervisory visit . . . The supervisory visit shall be made in the patient’s home or virtual call every 14 days or less.” Review of P4’s aide supervisory notes located in the electronic medical record (EMR) under “Other Notes” tab revealed the Director of Patient Care Services (DPCS) completed in person visits on 04/08/2025, 05/14/2025, and 06/26/2025. The aide supervisory visits documented for 04/21/2025 and 05/02/2025 were documented as having been completed via a phone call to the patient. No supervisory visits occurred between 05/21/2025 and 06/09/2025 due to the patient being in the hospital during that time. During an interview on 07/08/2025 at 10:00 AM, the DPCS stated the supervisory visit documentation was completed every 14 days. The DPCS stated, “Once a month it is completed by an in-person visit otherwise a phone call is made.” The DPCS was not aware of a requirement that supervisory visits were to be completed during an in-person visit or on rare occasion by using two-way audio-video telecommunications technology which should not exceed one virtual supervisory visit during a 60-day episode.”