Concordia Visiting Nurses

“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 review of policy, clinical records (CR), observations during a home visit, and staff interview, the agency failed to provide written instructions to the patient outlining the visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA for two (2) of three (3) records reviewed (CR1,& CR2). Review of agency policy on March 27, 2026, at 10:30 a.m. showed, “CONCORDIA VISITING NURSES SUBJECT: Overview of Available Agency Services Policy: IX-1 I. Policy ... Every effort is made to provide a comprehensive approach to care with continuity of care assignment. ... D. Coordination of Care Agency staff work as a team, conferring with each other and establishing goals and the care plan with the patient/caregiver. Coordination is accomplished through complete documentation, care conferences and electronic communication to assure efforts effectively complement one another and support the objectives outlined in the plan of care. All communication is documented in order to establish that effective interchange, reporting and coordinated patient evaluation and care implementation occurs.” Review of CR1 on March 26, 2026, at 9:30 a.m. showed a physician ordered plan of care with an initial certification period from 2/28/2026 to 4/28/2026. The patient was ordered physical therapy once per week for 1 week, twice a week for 1 week, and every other week for 2 weeks. After the initial PT start of care visit on 2/28/2026, the patient received PT services on 3/3, 3/6, and 3/9/2026. Further review of CR1 did not show the agency provided, or the patient received, written instructions outlining the visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. Interview with EMP1 at time of review noted that the patient’s are mailed their written instructions per an automated “work flow” process. Review of the documented process as described by EMP1 showed, “Event-Stages History Report ... Client Name: [CR1] ... Event ... Patient care coordination ... Print patient instructions and send to patient ... 3/3/2026.” The report was in tabular format sorted by date. EMP1 was not able to produce the written instructions that would have been sent to the patient because they are “living documents” and the patient was no longer an active patient. EMP1 confirmed there was no documentation in the clinical record concerning written instructions to the patient other than the “Event-Stages History Report.” Review of CR2 on March 26, 2026, at 10:30 a.m. showed a physician ordered plan of care with an initial certification period from 3/11/2026 to 5/9/2026. Orders initially included skilled nursing 3 times per week, physical therapy once per week, occupation therapy 2 times per week, speech therapy once a week, and a social worker visit once a week. For instance, the patient received skilled nursing visits on 3/11 (start of care), 3/13, 3/16, 3/18, 3/19, and 3/23/2026. The clinical record did not show the patient was provided or understood their written instructions concerning frequency of visits by HHA personnel and personnel acting on behalf of the HHA. EMP1 produced a “Patient Instructions Report” dated 3/18/2026 that included frequency of visits by discipline (nursing, physical therapy etc.) that would have been provided to CR2’s daughter, but EMP1 was unable to produce the initial written instructions provided to the patient and family or if those initial written instructions provided to the patient and family were understood by the patient and family. A review of documentation at CR2’s residence during a home visit with EMP1 present on March 25, 2026, at 12:12 p.m. did not show a visit schedule in the home that included frequency of visits by HHA personnel and personnel acting on behalf of the HHA. Interview with EMP1 at 11 a.m. confirmed above findings. EMP1 noted that the written instructions to the patient, included in the “work flow” process, are mailed to the patients. However, there was no documentation in the medical record to show staff confirmed if patient received and understood their mailed written instructions.”

“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 review of agency policy, clinical records (CR) and staff (EMP) interview, the agency failed to provide services in accordance with the plan of care for three (3) of three (3) patients with venous access devices (CR1-CR3). Findings included: Review of agency policy on February 3, 2026, at 1:45 p.m., “CONCORDIA VISITING NURSES ... Policy: IX-2 ... I. Policy Concordia Visiting Nurses provides nursing services to patients in need of nursing care at home in accordance with the physician’s or allowed practitioner’s written plan of care.” Review of agency policy on February 4, 2026, at 10 a.m. showed, “CONCORDIA VISITING NURSES ... Policy: XII-2 ... I. Policy ... M. Nurses will document all aspects of assessment, teaching, interventions, and appearance of IV site, as well as patient knowledge, and tolerance of IV therapy for each home visit.” Review of CR1 on February 3, 2026, at 11 a.m. revealed a physician ordered plan of care for an initial certification period from 9/24/2025 to 11/22/2025. Orders included skilled nursing (SN) to see the patient once a week for care and assessment related to patient’s peripherally inserted central catheter (PICC), “Skilled nurse ... for observation / assessment of IV access site.” Review of SN visit notes for treatment week beginning 11/16/2025 and ending 11/22/2025 did not show the patient received as skilled nurse visit as ordered that week. A coordination note showed, “CALL DATE: 11/21/2025 CALL TIME: 720 [a.m.] ... [Patient’s cousin] CALLED BECAUSE PATIENT CALLED [him/her] AND TOLD [him/her] NO ONE CALLED ABOUT PICC LINE CARE TODAY ... PT [patient] IS ON FOR RECERT IV VISIT TODAY ... RESOLUTION: CALL TO PT TO MAKE [him/her] AWARE THAT [his/her] COUSIN CALED AND THAT [nurse] IS ON THE CALENDAR FOR [his/her] VISIT TODAY AND [agency] WILL TEXT [nurse] TO CALL [patient] WITH VISIT TIME.” A coordination note from 11/21/2025 by agency nurse mentioned in above coordination note showed that he/she did not see the patient on 11/21/2025, “REASON FOR THE CHANGE: PT UNABLE NEW DATE REQUESTED: 11.22.25 ... WAS PATIENT NOTIFIED OF THE DATE CHANGE: YES.” There was no further documentation to show the patient received a visit on 11/22/2025 or for the treatment week beginning 11/16/2025 CR1’s recertification period was from 11/23/2025 to 1/21/2026. Orders included, “SKILLED NURSE ... FOR OBSERVATION / ASSESSMENT OF IV ACCESS SITE ... REGARDING INFUSION PROCEDURE CARE OF INFUSION LINE AND SITE CARE, CARE AND USE OF INFUSION EQUIPMENT ... DRESSING CHANGE FREQUENCY WEEKLY AND [as needed] ... CHANGE END CAPS WEEKLY AND WITH EVERY BLOOD DRAW.” Patient was also ordered to have labs done via his/her PICC line. “Lab orders: ... Flush [PICC] with 10-20ml saline before and after each lab draw as needed.” During the recertification visit on 11/23/2025, SN obtained labs via venipuncture (needle into vein) instead if using the patient’s PICC as ordered, and there was no order to obtain patient’s labs via venipuncture. The patient refused the PICC dressing change. There was no evidence the SN changed the end caps. A subsequent SN on 11/28/2025, and during the same treatment week, did not show the SN changed the end caps (documented as done on 11/24 when there was no SN visit), or the PICC dressing. SN obtained labs via venipuncture instead if using the patient’s PICC as ordered. A visit on 12/5/2025 showed SN obtained labs via venipuncture instead if using the patient’s PICC as ordered. Review of CR2 on February 4, 2026, at 11 a.m. revealed a physician ordered plan of care for an initial certification period from 11/2/2025 to 12/31/2025. Orders included SN to see the patient once a week for care and assessment related to patient’s IV access or midline catheter, “Skilled nurse ... for observation / assessment of IV access site.” SN provided 13 visits from 11/2-11/28/2025 but failed to conduct a midline IV access assessment for 8 of those visits on 11/3, 11/5, 11/7, 11/12, 11/14, 11/19, 11/21, and 11/26. For instance, the RN documented an unremarkable assessment concerning CR2’s midline IV access on 11/9/2025, “NO PROBLEMS WITH SITE,” which was a Sunday and the beginning of the treatment week. Subsequent SN visits were conducted on 11/12 and again on 11/14/2025 with no midline IV access assessment to show the IV site was intact and without problems just prior to a hospitalizations concerning problems with the IV site. The 11/14/2025 SN visit was completed at 2:10 p.m. Review of coordination notes showed patient called in the evening of 11/14/2025 at 7:50 p.m., CALLED IN STATING IN STATING THOUGHT IV WAS LEAKING.” On 11/15/2025, a coordination note showed the patient’s daughter called the agency to report the patient was going to the hospital emergency department because the patient’s IV site was leaking during the infusion. A coordination note from 11/17/2025 showed, “CALLED TO CHECK ON PATIENT. STATED HE GOT [his/her] NEW MIDLINE AT THE HOSPITAL THIS WEEKEND. AND WAS WAITING FOR THE NURSE TODAY.” Review of CR3 on February 4, 2026, at 10:30 a.m. showed patient was discharged from hospital with a PICC installed (1/20/2026) and admitted to agency on 1/24/2026 for IV antibiotics via PICC. The initial physician ordered plan of care, for certification period from 1/24/2026 to 3/24/2026, included orders for SN to see the patient once a week for care and assessment related to patient’s PICC, “Skilled nurse ... for observation / assessment of IV access site.” Review of SN initial start of care visit from 1/24/2026 did not show that the registered nurse provided and assessment of patient’s PICC or that there was a PICC in place. Interview with EMP3 (administrator) and EMP2 (COO) on February 4, 2026, at 12:30 p.m. confirmed above findings.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on review of agency policy, clinical records (CR), and staff (EMP) interview, the licensed practical nurse (LPN) and registered nurse (RN) failed to assume responsibility for the patient and failed to ensure an ongoing interdisciplinary assessment of the patient was completed for one (1) of one (1) discharged record with an indwelling urinary catheter who required emergency services (CR1). Review of facility policy on December 19, 2023, at 10:15 a.m. showed: “POSITION DESCRIPTION - REGISTERED NURSE ... DUTIES AND RESPONSIBILITIES ... N. Coordinates total patient care serving as the primary nurse for designated patients and evaluating the effectiveness and the appropriateness of care. ... P. Serves as the primary liasison and coordinator of care when nursing and other services are provided. ... R. Meets with the interdisciplinary team routinely to ensure coordination of care.” “POSITION DESCRIPTION - LICENSED PRACTICAL NURSE ... POSITION SUMMARY ... The LPN collaborates patient care with the case managing RN, physician, and patient ... DUTIES AND RESPONSIBILITIES ... F. ... Conducts a comprehensive physical examination and nursing assessment of the patient at each skilled visit.” “Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) ... PROCEDURE ... 13. Inspect urine for color, clarity, and amount ... 24. Document procedure in the patient’s record. EXPECTED OUTCOMES ... Urine drains properly ... DOCUMENTATION ... Time of catheter care ... Character, amount, color, and odor of urine.” “Skills: Urinary Catheter: Indwelling (Foley) Catheter Care ... 9. Inspect the urine in the collection chamber for color, clarity, and quantity. ... 22. Document the procedure in the patient’s record.” “Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Male) (Home Health Care) ... Catheter Insertion ... 9. Perform a patient assessment, including: ... b. Intake and output ... 32. Insert the catheter. a. Indwelling or straight catheter ... iii. Advance the indwelling catheter ... until urine flows through the tubing. ... 42. Observe the characteristics and amount of urine in the drainage system. ... 46. Document the procedure in the patient’s record. ... UNEXPECTED OUTCOMES ... No urine in catheter drainage bag. ... DOCUMENTATION ... Amount of urine drained.” Review of CR1 on December 20, 2023, at 10 a.m. showed a physician ordered plan of care with a start of care date of 10/19/2023 for an initial certification ending 12/17/2023. The patient’s admitting diagnosis was heart disease with a medical history of urinary retention and consequent indwelling urinary catheter (a tube inserted into the body to drain urine from the bladder). Orders included, “Skilled nurse to assess/evaluate co-morbid conditions including ... other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications ... Skilled nurse to perform observation / assessment of genitourinary status and intervene to minimize complications of disease process. Skilled nurse for insertion of Foley [urinary] catheter maintenance ... change [every] month.” The plan of care was signed by the RN on 10/19/2023. Review of CR1’s skilled nursing visit notes showed the RN completed the initial comprehensive assessment on 10/19/2023. The RN noted the patient had an indwelling urinary catheter (catheter inserted into bladder for long-term placement), “ Has [urinary catheter] in place that SN [skilled nursing] to manage.” CR1 received another seven (7) SN visits over a 35-day period before an emergency room visit on 11/25. All the visits were provided by an LPN on 10/24, 10/27, 10/31, 11/3, 11/16, 11/24/2023, and 11/29/2023. During six (6) of seven (7) visits (10/24-11/24/2023) the LPN failed to document the amount of urine in the patient’s urinary catheter drainage bag. During the 10/24/2023 and 11/24/2023 visits, the LPN replaced the patient’s urinary catheter and simply documented the patient’s urinary catheter was last changed on 10/24/2023 for example. Review of CR1’s emergency room visit from 11/25/2023 showed patient was registered at 4:42 a.m., “Triage Presenting Complaint and Acuity Level: foley [urinary] catheter not draining bladder scan for over 1,000 [over 1 liter of urine found in bladder] pt reports home health placed a foley today [ was yesterday 11/24/2023] no out put [sic] appreciated through out [sic] the day and night ... ED [emergency department] COURSE: ... 87 year-old ... male presents to the emergency department with acute retention of urine. ... Foley catheter placed yesterday by the home health nurse and the catheter never drained. Patient is in a lot discomfort and is in acute retention of urine. The foley catheter was deflated and pushed back when he started draining and more than a liter if urine has been drained. Patient feels very comfortable after repositioning of the Foley catheter and decompression of the bladder.” There was nothing in the above visit notes to show the RN supervised the LPN over the 40-day episode (10/19 to 11/29) to ensure the patient’s needs were met or if the LPN was following agency policy concerning urinary catheter care. CR1 was reviewed with EMP1 (administrator), and EMP3 (chief nursing officer) on December 19, 2023, at 1 p.m. EMP3 looked at each LPN visit note and confirmed the LPN failed to document how much urine was in patient’s urinary catheter drainage bag from 10/24-11/24/2023 visits, or if urine was obtained when new urinary catheter was inserted on 10/24/2023 and 11/24/2023. EMP3 also confirmed no RN supervision for the entire episode when care was provided by the LPN.”

“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 review of agency policy, clinical records (CR), and staff (EMP) interview, the registered nurse (RN) failed to supervise, monitor and evaluate the performance of the licensed practical nurse (LPN) regarding data collection to ensure the patient’s needs were met as delegated by the RN for one (1) of one (1) discharge record with an indwelling urinary catheter who required emergency services (CR1). Review of facility policy on December 19, 2023, at 10:15 a.m. showed: “SUBJECT: Nursing Services Policy: IX-2 I. Policy Concordia Visiting Nurses provides nursing services to patients in need ... The qualified License Practical Nurse (LPN) ... may provide nursing services under the supervision of the registered nurse. A. Provider Care ... The RN is responsible for all aspects of the nursing process including: ... provision of skilled care ... observation of clinical signs and symptoms ... assignment and supervision of the LPN. ... The LPN may provide care under the guidance and supervision of the RN.” “POSITION DESCRIPTION - REGISTERED NURSE ... DUTIES AND RESPONSIBILITIES ... H. Supervises and periodically evaluates the care given by the LPN to his/her primary patients to ensure oversight I. Evaluates and manages LPNs ... who are providing services to his/her patients. ... Coordinates total patient care serving as the primary nurse for designated patients and evaluating the effectiveness and the appropriateness of care.” “Skills: Urinary Catheter: Indwelling (Foley) Catheter Care (Home Health Care) ... PROCEDURE ... 13. Inspect urine for color, clarity, and amount ... 24. Document procedure in the patient’s record. EXPECTED OUTCOMES ... Urine drains properly ... DOCUMENTATION ... Time of catheter care ... Character, amount, color, and odor of urine.” “Skills: Urinary Catheter: Indwelling (Foley) Catheter Care ... 9. Inspect the urine in the collection chamber for color, clarity, and quantity. ... 22. Document the procedure in the patient’s record.” “Skills: Urinary Catheter: Straight and Indwelling (Foley) Catheter Insertion (Male) (Home Health Care) ... Catheter Insertion ... 9. Perform a patient assessment, including: ... b. Intake and output ... 32. Insert the catheter. a. Indwelling or straight catheter ... iii. Advance the indwelling catheter ... until urine flows through the tubing. ... 42. Observe the characteristics and amount of urine in the drainage system. ... 46. Document the procedure in the patient’s record. ... UNEXPECTED OUTCOMES ... No urine in catheter drainage bag. ... DOCUMENTATION ... Amount of urine drained.” Review of CR1 on December 20, 2023, at 10 a.m. showed a physician ordered plan of care with a start of care date of 10/19/2023 for an initial certification ending 12/17/2023. The patient’s admitting diagnosis was heart disease with a medical history of urinary retention and consequent indwelling urinary catheter (a tube inserted into the body to drain urine from the bladder). Orders included, “Skilled nurse to assess/evaluate co-morbid conditions including ... other conditions that present themselves during the course of the episode to identify changes and intervene to minimize complications ... Skilled nurse to perform observation / assessment of genitourinary status and intervene to minimize complications of disease process. Skilled nurse for insertion of Foley [urinary] catheter maintenance ... change [every] month.” The plan of care was signed by the RN on 10/19/2023. Review of CR1’s skilled nursing visit notes showed the RN completed the initial comprehensive assessment on 10/19/2023. The RN noted the patient had an indwelling urinary catheter (catheter inserted into bladder for long-term placement), “ Has [urinary catheter] in place that SN [skilled nursing] to manage.” CR1 received another seven (7) SN visits over a 35-day period before an emergency room visit on 11/25. All of the visits were provided by an LPN on 10/24, 10/27, 10/31, 11/3, 11/16, 11/24/2023, and 11/29/2023. During these visits the LPN failed to document the amount of urine in the patient’s urinary catheter drainage bag. During the 10/24/2023 and 11/24/2023 SN visits, the LPN replaced the patient’s urinary catheter and simply documented the patient’s urinary catheter was last changed on 10/24/2023. There was no documentation to show how much urine was in patient’s urinary catheter drainage bag, and if urine was obtained when new urinary catheter was inserted. There was nothing in the above visit notes to show the RN supervised the LPN over the 40-day episode (10/19 to 11/29) to ensure the patient’s needs were met or if the LPN was following agency policy concerning urinary catheter care. Review of CR1’s emergency room visit from 11/25/2023 showed patient was registered at 4:42 a.m., “Triage Presenting Complaint and Acuity Level: Foley [urinary] catheter not draining bladder scan for over 1,000 [over 1 liter of urine found in bladder] pt reports home health placed a foley today [ was yesterday 11/24/2023] no out put [sic] appreciated through out [sic] the day and night ... ED [emergency department] COURSE: ... 87 year-old ... male presents to the emergency department with acute retention of urine. ... Foley catheter placed yesterday by the home health nurse and the catheter never drained. Patient is in a lot discomfort and is in acute retention of urine. The foley catheter was deflated and pushed back when he started draining and more than a liter if urine has been drained. Patient feels very comfortable after repositioning of the Foley catheter and decompression of the bladder.” CR1 was reviewed with EMP1 (administrator), and EMP3 (chief nursing officer) on December 19, 2023, at 1 p.m. EMP3 looked at each LPN visit note and confirmed there was no documented supervision by the RN for the entire episode. The patient was discharged by the RN on 12/19/2023.”