Vana Home Health Inc.

“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: Based on record review and interview, the agency failed to ensure a completed transfer summary was sent within two business days after becoming aware of an unplanned transfer to a healthcare facility and failed to complete a discharge summary for one (Patient #8) of three discharged patient records reviewed, in that Patient #8 was transferred to the hospital on 2/24/2026, the agency was notified of the hospitalization on 2/25/2026 while the patient remained hospitalized, and the agency failed to complete and send a transfer summary. The agency subsequently discharged Patient #8 from home health services on 2/27/2026 and failed to complete a discharge summary. As a result of the failure, pertinent information regarding Patient #8’s diagnosis, baseline status, medications, history, home health services, and status at transfer and discharge was not summarized and provided to the healthcare providers responsible for the patient’s continued care. The failure placed Patient #8 at an increased risk for lack of continuity and coordination of care, medication discrepancies, and healthcare providers being unaware of the patient’s baseline and current healthcare needs. Findings include: Patient #8 Record review of Patient #8’s clinical record revealed the patient was transferred to the hospital on 02/24/2026. Review of a Physical Therapy Assistant note dated 2/25/2026 revealed the patient’s daughter reported that Patient #8 had been admitted to the hospital on 2/24/2026 and the supervisor was notified by phone. Further review revealed the clinical record contained no transfer summary and no documentation that a transfer summary was sent to the hospital. An OASIS (Outcome and Assessment Information Set) Transfer assessment was completed on 03/24/2026. Further review revealed Patient #8 was discharged from the agency on 2/27/2026 after the agency learned the patient was being discharged from the hospital to a skilled nurse facility (SNF). An OASIS Discharge assessment was completed. The clinical record contained no discharge summary for Patient #8. Interview on 08/26/2026 at 10:12 AM with Administrator/Supervising Nurse and Alternate Administrator revealed the agency most often received information regarding a patient’s transfer from the caregiver, and if the agency sent the patient out, the agency would send the patient’s medication list. The Surveyor asked what documentation was required when a patient was transferred and the Administrator/Supervising Nurse stated the patient was placed on transfer hold; however, if the recertification date passed, the transfer became a discharge. The Surveyor asked who was responsible for completing and sending the transfer summary. The Administrator/Supervising Nurse stated she, as the Supervising Nurse, and the Alternate Supervising Nurse were. The Surveyor asked when the agency learned of Patient #8’s hospital transfer on 2/25/2026, and whether Patient #8 was still admitted to the hospital. The Administrator/Supervising stated, “Yes” The Surveyor asked when Patient #8 was discharged from the hospital to the SNF. The Administrator/Supervising Nurse stated, “When we discharged them from the agency.” The Surveyor asked whether completing the OASIS Transfer assessment replaced the transfer summary or whether the agency required both, and the Administrator/Supervising Nurse stated, “both.” The Surveyor asked the required timeframe for sending the transfer summary and the Administrator/Supervising Nurse stated, “48 hours.” The Surveyor asked why a transfer summary was not completed for Patient #8 and the Administrator/Supervising Nurse stated, “I don’t recall.” The Surveyor asked what process the agency followed when it learned Patient #8 was discharged from the hospital to the SNF and the Administrator/Supervising Nurse stated the hospital social worker called and reported the patient was going to a SNF, and the agency completed a normal discharge, which included an OASIS Discharge assessment. The Surveyor asked who was responsible for completing the discharge summary and the Administrator/Supervising Nurse stated she and the Alternate Supervising Nurse were. The Surveyor asked why the discharge summary was not completed and the Administrator/Supervising Nurse stated, “I don’t recall not doing it.” The Surveyor asked what information was usually included in a transfer and discharge summary sent to another healthcare provider and the Administrator/Supervising Nurse stated diagnosis, vital signs, history, medications, and the reason for the discharge. The Surveyor asked how failing to send the information could negatively affect patient #8 and the Administrator/Supervising Nurse stated the hospital would not know the patient’s baseline or the medications the patient was taking. The Surveyor asked what could have been done differently and the Administrator/Supervising Nurse stated, “send the summary.” Review of the agency policy titled, “Patient Transfer/Agency Dissolution,” revised on 12/01/06 revealed the following, “…Agency will contact the receiving agency to advise them of the transfer, coordinate the transfer date and patient/client care, and establish any specific transfer conditions. Prior to, but no later than forty-eight (48) hours after the transfer, the Agency will provide the receiving agency with the following: 1. Services being rendered 2. Specific care 3. Medication 4. Psychosocial Status 5. Other organizations involved in the patient/client care 6. Any existing Advance Directives, DNR (Do Not Resuscitate) status, Medical Power of Attorney and/or Living Will…” Review of the agency policy titled, “Criteria for Patient Admission and Discharge,” revised 03/01/2025, revealed the following, “PURPOSE: The Agency will review each request for admission/discharge for appropriate criteria for home care… V. The Agency will complete a discharge summary within 30 days of discharge from home health…” Review of the agency policy titled, “Patient Discharge,” revised 12/01/2006, revealed the following, “PURPOSE: To ensure an appropriate, timely, coordinated discharge process… 9. The patient/client/caregiver will be educated on aspects of post-discharge continuity of care arrangements… 10. All disciplines involved will be notified of the discharge date… 11. Medical record documentation includes, but is not limited to: Discharge summary/progress toward goals; Discharge orders, if skilled care is being provided…””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on interview and record review, the agency failed to include all the clinical notes in the patients clinical record in 3 of 5 patients (Pt 1, Pt 2, Pt 3) whose records were reviewed. This failure resulted in incomplete and untimely clinical documentation, preventing the agency from demonstrating that services provided were accurately and promptly documented in the patient record. Findings include: Record review of Pt 1’s clinical record revealed a start of care date of 2/2/2026 and a certification period of 4/3/2026-6/1/2026 was reviewed. Pt 1 had a diagnosis of GERD (a condition where stomach acid flows backward into the tube connecting your mouth and stomach) and was ordered to receive skilled nursing visits 1 time a week for 9 weeks. Additional skilled nursing orders included: obtaining vital signs (measuring blood pressure, body temperature, heart rate), monitor food and water intake, and educating Pt 1 on GERD. Review of clinician visit schedule for a period of 4/3/2026-5/2/2026 revealed skilled nursing visits scheduled for 4/9, 4/16, 4/23, 4/30 with a status of “Still Due” listed for each. Review of clinician visit schedule for a period of 6/2/2026-7/1/2026 revealed skilled nursing visits scheduled for 6/4, 6/11, 6/18, 6/25 with a status of “Still Due”. Each visit date revealed no evidence of the nurse performing documentation for these visits. Record review of Pt 2’s clinical record revealed a start of care date of 1/5/2026 with a primary diagnosis of GERD and was ordered to receive skilled nursing visits 1 time per week for 9 weeks. Additional skilled nursing orders included: vital signs (measuring blood pressure, body temperature, heart rate) and educating Pt 2 on GERD. Review of clinician visit schedule for period June 2026 revealed skilled nursing visit scheduled for 6/25 with a status of “Still Due” listed for this visit. Review of clinician visit schedule for July 2026 revealed skilled nursing visits for 7/9, 7/16 scheduled with a status of “Still Due”. Each visit date revealed no evidence of the nurse performing documentation for these visits. Record review of Pt 3’s clinical record revealed a start of care date of 3/24/2026 with a primary diagnosis of osteoarthritis (wear and tear of the cushion on the ends of bones causing the bones to rub against each other). Skilled nursing visits were ordered 2 times per week for 1 week and 1 time per week for 8 weeks. Additional skilled nursing orders included: vital signs (measuring blood pressure, body temperature, heart rate), educating Pt 3 on osteoarthritis, and monitoring food and water intake. Review of clinician visit schedule for May 2026 revealed a skilled nursing visit scheduled for 5/27 with a status of “Still Due” listed for this visit. Review of scheduled for June 2026 revealed skilled nursing visits scheduled for 6/3, 6/10, 6/17 with a status of “Still Due” listed for each visit. Each visit date revealed no evidence of the nurse performing documentation for these visits. Record review of LVN A employment file revealed a hire date of 5/7/2020. Employee evaluations were completed on 8/7/23, 8/7/24, and 8/27/25. Employee record revealed no disciplinary action or documentation of incomplete visit notes being addressed. A phone interview with Pt 2 on 7/21/26 at 3:50 PM was conducted. Pt 2 stated her nurse always shows up for scheduled appointments and that she loved the care that he provided. Pt 2 expressed no concerns with the skilled nursing services that she was receiving from the agency. During an interview with agency Alt Admin on 7/20/26 at approximately 2:30 PM, Surveyor asked Alt Admin why the nursing notes were missing on so many visits and if she had confirmed that visits were being made. Alt Admin stated the reason she was given by LVN A for notes not being complete was that he is often tired at the end of the day. Alt Admin stated the expectation is nursing notes are completed in a timely manner. Alt Admin stated it is the responsibility of the DON/ Admin to ensure that patient notes are submitted in a timely manner. Admin was not available for interview at this time due to physical limitations. An interview with LVN A on 7/21/26 approximately 12:00 PM was conducted. Surveyor asked LVN A why he was not entering nursing notes on the patients that he was seeing. LVN A stated that sometimes he has internet issues and can’t complete the nursing notes. Review of agency policy titled “Medical Record Information Timeline”, revised 5/1/14, read in part, “…daily progress notes are turned in every 7 days and incorporated into the medical record within 14 business days. Notes will be written day of service…”.”