VNA Home Health

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on the Home Health Agency (HHA) Error Summary by Agency Report for the period 01/01/2024 through 12/31/2024, the agency failed to encode and electronically transmit each completed Outcome and Assessment Information Set (OASIS), regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary. Failure to encode and electronically transmit each complete OASIS assessment, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within thirty days of completing the assessment of the beneficiary has the potential for incorrect and incomplete reporting data. FindingOn 04/29/2025 the surveyors reviewed the Certification and Survey Provider Enhanced Reports (CASPER), “Home Health Agency Error Summary Report by Agency” for report period 01/01/2024 - 12/31/2024. The report contains a warning code -3330 “Record Submitted Late”: The submission date is more than thirty days after M0090 “Date Assessment Completed” on this new record. The CASPER Report states 23 (0.34%) out of 6733 assessments processed were submitted more than thirty days after M0090. Their is no documented evidence the agency submitted the required documents timely for 23 out of 6733, or for 0.34% of submissions. The finding was confirmed on 05/09/2025 at 11:00 AM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.”

“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 clinical record review and staff interview the agency failed to ensure services are provided in accordance with the Plan of Care (POC) in one of seventeen records (Patient # 12). Failure to follow the POC has the potential for patients to receive care inconsistent with the physician’s orders resulting in unmet patient needs and possible negative patient outcomes. Patient # 12 (start of care 12/12/2019) has diagnoses of Encounter for Adjustment and Management of Ventricular Assist Device (VAD) and Fistula of Intestine. The record contains Visit Note Reports (dated 03/18/2025, 03/25/2025, 04/01/2025 and 04/08/2025) that state “Central line dressing changed via sterile technique, cleaned, replaced Biopatch flushed with 10 milliliters (ml) normal saline (NS), 5 ml heparin, replaced cap and flushed with another 10 ml of NS.” The POC for certification period 03/15/2025 through 05/13/2025 does not contain orders for a dressing change or flushes to the central line. The findings were confirmed on 05/07/2025 at 3:00 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.”

“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 clinical record review and staff interview the agency failed to ensure a complete Plan of Care (POC) was developed to meet the individualized needs of the patient in five out of seventeen records (Patient # 2, 6, 11, 13 and 17). Failure to develop a comprehensive POC has the potential for unmet patient needs and places patients at risk for receiving incorrect and/or inappropriate care. Patient # 2 (start of care 05/04/2025) has diagnosis of Dehiscence of Amputation Stump. The POC for certification period 05/04/2025 through 07/02/2025 contains an order for: Oxygen (O2) gas for inhalation O2 - Continuous Positive Airway Pressure (CPAP) / Bilevel Positive Airway Pressure (BiPAP) and concentrator 2 Liter bedtime Patient / Caregiver manages. The order is incomplete as it is lacking the route of administration for the oxygen: mask and/or nasal canula and oxygen precautions.Patient # 6 (start of care 02/19/2025) has diagnoses of Spinal Stenosis, Lumbar Region without Neurogenic Caudation and Other Intervertebral Disc Displacement, Lumbar Region. The record contains POC’s for certification periods 02/29/2025 through 04/19/2025 and 04/20/2025 through 06/18/2025 that both contain an order for: Fluticasone Propionate 50 micrograms (mcg) / actuation nasal 2 spray daily/as needed (PRN) as needed for nasal congestion-no more than 2 doses in 24 hours. The orders are incomplete as they are lacking instruction as to which Nare, or both to take the medication.Patient # 11 (start of care 02/28/2025) has diagnoses of Pressure Ulcer of Left Heel, Stage 3 and Atrial Fibrillation. The POC for certification period 04/29/2025 through 06/27/2025 contains an order for: Ibandronate 150 milligrams (mg) oral 1 tablet monthly Every 30 days, next dose due 03/01/2025 at 6 AM. The order requires clarification for the correct next due date, or if the medication has been discontinued.Patient # 13 (start of care 04/04/2024 discharged 11/29/2024 has diagnoses of Pressure Ulcer of Right Heel, Stage 2 and Unspecified Fracture Shaft of Left Tibia Subsequent for Closed Fracture with Routine Healing. The POC for certification period 10/01/2024 through 11/29/2024 contains orders for: Lidocaine 5 % Topical Patch topical 1 adhesive patch medicated daily Apply to lower back. The order requires clarification as to how long to leave the patch on and/or removal instructions and Silver Sulfadizine 1% Topical Cream Topical per instructions 3 times daily Apply to affected area 3 times (X) a day. The order is incomplete as it requires a specified anatomical location to apply the cream.Patient # 17 (start of care 01/15/2023 discharged 04/30/2025) has diagnoses of Other Chronic Pain and Bilateral Primary Osteoarthritis of Knee. The POC for certification period 01/04/2025 through 03/04/2025 contains an order for: Oxygen Gas for Inhalation 3% O2 continuous Supplied by (oxygen company) Oxygen for out of home. The order is incomplete as it is lacking the route of administration for the oxygen: mask and/or nasal canula and oxygen precautions;The POC for certification period 03/05/2025 through 05/03/2025 contains an order for: Oxygen Gas for Inhalation 2 Liter as directed Supplied by (oxygen company) Oxygen for out of home. The order is incomplete as it is lacking the dosage, route of administration for the oxygen: mask and/or nasal canula and oxygen precautions;Xarelto 15 mg tablet oral 1 tablet daily. The orders are incomplete as they are lacking bleeding precautions related to anticoagulant medication use.The findings were confirmed on 05/06/2025 at 3:15 PM, 05/07/2025 at 3:00 PM and 05/08/2025 at 1:45 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on clinical record review and staff interview evidence is lacking in one of seventeen records (Patient # 14) the physician was contacted regarding changes that alter or suggest the need to alter the Plan of Care (POC). Failure to consult with the physician when changes occur in the patient’s condition has the potential for unmet patient needs and/or negative patient outcomes. Patient # 14 (start of care 11/15/2024 discharged 01/09/2025) has diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation and Acquired Absence of Right Leg Below Knee. The POC for certification period 11/15/2024 through 01/13/2025 contains an order for: Wound care to suture site located on right lower extremity (RLE) below the knee amputation (BKA) using clean technique daily. Apply betadine paint, allow to dry, cover with bordered gauze dressing or non-adherent gauze and abdominal pad (ABD), secure with roll gauze/tape and ace wrap. The record contains a Visit Note Report (dated 12/05/2024) that states “ Patient (Pt) seen by surgeon this week, all staples/sutures removed. Wound is well approximated, open to air (OTA). Pt states he would like me to wrap it with Kling gauze (which I did) and he then applied the shrinker”. The record lacks documented evidence the physician was notified of the need to change the dressing order or to add the durable medical equipment of a shrinker. The finding was confirmed on 05/08/2025 at 1:45 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.”

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on clinical record review and staff interview the agency failed to ensure adequate supervision of the Licensed Practical Nurse (LPN) staff in two of seventeen records reviewed (Patient # 4 and 14). Failure to adequately supervise LPN staff has the potential to result in the provision of inappropriate and/or incorrect care and negative patient outcomes. Patient # 4 (start of care 04/02/2025) has diagnoses of Pressure Ulcer of Sacral Region, Stage 4 and Pressure Ulcer of Other Site, Stage 2. The record contains Visit Note Reports (dated 04/11/2025, 04/14/2025, 04/18/2025, 04/23/2025, 04/28/2025, 04/30/2025 and 05/02/2025) and a Client Episode Coordination Note (dated 04/16/2025) completed by the licensed practical nurse (LPN) that state “no signs or symptoms of infection noted”. Performing a nursing assessment is outside the LPN’s scope of practice. Also, the record lacks documented evidence the Registered Nurse (RN) reviewed the LPN Visit Note Reports to ensure the supervision of appropriate care. Patient # 14 (start of care 11/15/2024 discharged 01/09/2025) has diagnoses of Encounter for Orthopedic Aftercare Following Surgical Amputation and Acquired Absence of Right Leg Below Knee. The record contains Visit Note Reports (dated 11/20/2024, 11/26/2024) completed by the LPN. The record is lacking documented evidence the RN reviewed the LPN Visit Notes to ensure the supervision of appropriate care. The findings were confirmed on 05/06/2025 at 3:15 PM and 05/08/2022 at 1:45 PM with the Administrator and Executive Director of Clinical Operations; no additional evidence was provided.”