Every finding on record at 1st American Home Health Care Services

One (1) Medical Facilities Inspector (MFI) from the Office of Licensure and Certification (OLC), Virginia Department of Health (VDH) conducted an unannounced Home Health Medicare Recertification Survey on July 12 - 13, 2021. As part of the inspection process, the agency's Emergency Preparedness Plan was reviewed. The agency was found to be in compliance with 42 CFR 484.113, the Condition of Participation - Emergency Preparedness for Home Health Agencies.

One (1) Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health, conducted an unannounced Medicare/Medicaid home health recertification survey at the above-noted agency from July 12, 2021 to July 13, 2021. The agency reported 17 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of seven (7) patients, two (2) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver and three (3) home visits and multiple staff interviews were conducted. The agency was found not to be in compliance with 42 CFR 484, the Medicare Conditions of Participation for Home Health Agencies. Standard level deficiencies were identified and cited in this report.

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 review of clinical records and staff interview, it was determined the agency failed to send the patient's discharge summary to the primary care physician within 5 business days of the patient's discharge for two (2) of two (2) discharged patients in the survey sample (Clinical records #4 and #5). The findings: Two (2) discharged clinical records were reviewed onsite from 7/12-13/2021 as paper chart access with the following findings: 1. The clinical record for patient #4 was reviewed for the certification period of 4/22/2021 to 6/20/2021. The record revealed that the patient was discharged from the agency on 6/11/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 2. The clinical record for patient #5 was reviewed for the certification period of 3/18/2021 to 5/16/2021. The record revealed that the patient was discharged from the agency on 5/1/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. On 7/13/2021 at 1:00 PM the MFI (Medical Facilities Inspector) asked the Administrator for the discharge summary to the physician. The Administrator stated, we only send it if physician requested. The lack of providing a discharge summary within 5 business days of the patient's discharge was acknowledged prior to and reviewed during the exit conference with the Administrator on 7/13/2021 at 5 PM.