VNA of Care New England

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to obtain signature and maintain evidence in the clinical record to support they informed the patient of the bill of rights and provided a copy of such to the patient prior to the initiation of services, for 1 of 1 patient reviewed for confirmation of written notice of patient rights and responsibilities, Client ID #1. Findings are as follows: Review of the patient’s record revealed s/he was admitted to the Agency on 1/15/2025, for skilled services. Additional review of the clinical record failed to reveal evidence that the patient was informed of his/her rights prior to the initiation of services and provided with a written notice of patient rights and responsibilities that was signed by the patient and maintained in his/her clinical record as evidenced by the clinical record not containing such documentation. During a surveyor interview with the Director of Nursing Services on 2/25/2025 at 11:41 AM, she was unable to provide evidence that the Agency provided the patient with a written notice of patient rights and responsibilities which was reviewed with and signed by the patient prior to the initiation of services, and maintained in the clinical record, as required.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to consult with and obtain a signed consent regarding planned services and care prior to the initiation of services, for 1 of 1 patient reviewed for consultation and consent to treatment, Client ID #1. Findings are as follows: Review of the patient’s record revealed s/he was admitted to the Agency on 1/15/2025 for skilled services. Further record review revealed the patient received a total of 8 visits prior to being discharged from services with the last visit conducted on 2/11/2025. Additional review of the clinical record failed to reveal evidence that the Agency consulted with the patient about care services and obtained a signature for consent to treat, prior to the initiation of services. During a surveyor interview with the Director of Nursing Services on 2/25/2025 at 11:41 AM, she acknowledged that the patient’s clinical record lacked evidence of there being a signed consent and therefore, was unable to provide evidence that the Agency consulted with and obtained consent from the patient prior to administering care and initiating services, as required.”

“Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient’s behavior, the behavior of other persons in the patient’s home, or situation; This Element is not met as evidenced by: This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to attempt or make effort to resolve a problem presented by a patient’s behavior and failed to ensure the clinical record contained documentation of efforts taken to reduce and/or eliminate the problem (s), for 1 of 1 patient reviewed for an Agency initiated discharge, Client ID #1. Findings are as follows: Review of the patient’s clinical record revealed s/he was admitted to services on 1/15/2025 for skilled services with diagnoses including, but not limited to depression, history of suicidal ideation, and heart failure. Additional record review revealed the patient received a total of 8 home visits since his/her start of care and prior to the Agency initiating a discharge. Review of a note dated 2/11/2025, and authored by Physical Therapist, Staff A, states in part, “…PT (physical therapy) arrived during scheduled slot…Pt (patient) asleep on the couch and immediately in a foul mood…yelling…is angry…swearing about situation…depression…PT provided active listening and advised Pt not appropriate to yell at clinician…did calm down for a period of time…again started yelling when landlord entered the apartment…this pushed the Pt further yelling that things are not ok…started yelling…swearing…landlord got upset with Pt… two of them started yelling at each other…PT knew it was time to leave the home…Pt approached PT…shaking and crying…obviously more upset…PT attempted to deescalate Pt verbally with deep breathing…advised Pt that PT was leaving and would speak with the team to determine what assistance could be provided…kept swearing and crying…slammed fist down on the coffee table…PT left the home and immediately called VNA CNE…spoke with clinical manager…Staff B regarding the situation and advised he will call the pts PCP (primary care physician) to inform them of the incident and discuss discharge…” Further review of the patient’s clinical record failed to reveal documentation or evidence of any previous behaviors or incidents reported by staff and on behalf of the patient. In addition, record review failed to reveal evidence the Agency gave sufficient notice to the patient prior to discharge or made an effort to reduce or eliminate the problem before discharging the patient. During a surveyor interview with Clinical Manager/Registered Nurse, Staff B, on 2/25/2025 at 12:57 PM, he acknowledged the patient had other home visits prior to the one conducted on 2/11/2025. Staff B revealed the patient had been seen by nursing, occupational therapy and a social worker before the visit with the Physical Therapist on 2/11/2025. Staff B revealed there were no other reports of behaviors and acknowledged the behavior exhibited by the patient during the visit on 2/11/2025 was isolated in nature. In addition, Staff B was unable to provide evidence that the Agency made effort to continue to work with the patient in effort to resolve or eliminate the problem/behavior before making the decision to discharge the patient. Staff B acknowledged the last visit provided to the patient was on 2/11/2025 and therefore, was unable to provide documented evidence that is maintained in the clinical record of effort made by the Agency to try to reduce and/or eliminate the behavior/problem prior to initiating a discharge, as required.”

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to provide the patient with contact information for other agencies or providers who may be able to provide care to the patient prior to initiating a discharge, for 1 of 1 patient reviewed for an Agency initiated discharge, Client ID #1. Findings are as follows: Review of the patient’s clinical record revealed the patient was admitted to skilled services on 1/15/2025. Review of the scheduled visits provided to the patient revealed s/he had visits on the following dates: -1/15/2025 -1/24/2025 -1/27/2025 -1/31/2025 -2/3/2025 -2/5/2025 -2/10/2025 -2/11/2025 Review of a note dated 2/11/2025, and authored by Physical Therapist, Staff A, who conducted a home visit on 2/11/2025 states in part, “…PT (physical therapy) arrived during scheduled slot…Pt (patient) asleep on the couch and immediately in a foul mood…yelling…is angry…swearing about situation…depression…PT provided active listening and advised Pt not appropriate to yell at clinician…did calm down for a period of time…again started yelling when landlord entered the apartment…this pushed the Pt further yelling that things are not ok…again started yelling and swearing…landlord got upset with Pt…the two of them started yelling at each other…PT knew it was time to leave the home…Pt approached PT…shaking and crying and obviously more upset…PT attempted to deescalate Pt verbally with deep breathing and advised Pt that PT was leaving and would speak with the team to determine what assistance could be provided…s/he kept swearing and crying…slammed fist down on the coffee table…PT left the home and immediately called VNA CNE…spoke with clinical manager…Staff B regarding the situation and advised he will call the pts PCP (primary care physician) to inform them of the incident and discuss discharge…” Review of a note dated 2/12/2025 and authored by Registered Nurse, Clinical Manager, Staff B states in part, “…call back…PCP office…in agreement with agency DC…” Further record review failed to reveal evidence there was serious or imminent threat of physical harm exhibited toward staff during the above-mentioned visits. The behavior as documented in the patient’s clinical record that describes the behavior exhibited by the client during the visit on 2/11/2025 included yelling, swearing, slamming his/her fist down on a table, all of which do not pose threat to staff. There was no documentation related to the patient threatening to harm the staff or attempting to do so during any visits provided by the Agency. In addition, review of the clinical record failed to contain a follow up assessment by a licensed clinician rather revealed a telephone call was made to the patient by the clinical manager who informed the patient of the Agency’s decision to discharge the patient. There was no evidence of documentation as related to the offer of help, or resources which included contact information of provider names who may have been able to provide services to the patient after being discharged from the Agency. During a surveyor interview with Clinical Manager, Registered Nurse, Staff B, on 2/25/2025 at 12:57 PM, he acknowledged the Agency initiated a discharge based on the isolated incident on 2/11/2025 in which the patient exhibited inappropriate behavior during the home visit. He further revealed that he spoke with the patient and notified him/her that his/her PCP would assist with securing services and acknowledged that he nor anyone from the Agency provided the patient with contact information or resources as related to other HHA’s (home health agencies) that could have provided him/her with services after the Agency facilitated a discharge, as required.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: This element is NOT MET as evidenced by: Based on record review and staff interview, it has been determined the Agency failed to complete a discharge summary on behalf of a facility-initiated discharge, for 1 of 1 patient reviewed for discharge summary documentation, Client ID# 1. Findings are as follows: Review of the patient’s clinical record revealed s/he was discharged from the Agency after a home visit was conducted on 2/11/2025. Further record review failed to reveal evidence the Agency completed a discharge summary that was sent to the patient’s physician within 5 days of discharge and is maintained in the clinical record containing the following: · Admission and discharge dates; · Physician responsible for the home health plan of care; · Reason for admission to home health; · Type of services provided and frequency of services; · Laboratory data; · Medications the patient is on at the time of discharge; · Patient’s discharge condition; · Patient outcomes in meeting the goals in the plan of care; and · Patient and family post-discharge instructions. During a surveyor interview with the Director of Nursing Services on 2/25/2025 at 11:41 AM, she acknowledged that the patient’s clinical record maintained by the Agency lacked evidence of a discharge summary as indicated above and required.”