Every finding on record at Abby Home Healthcare

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on June 27-29, 2022 by two (2) Medical Facilities Inspectors from the Virginia Department of Health Office of Licensure and Certification. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found not to be in compliance with 42 CFR 484.102 the Conditions of Participation: Emergency Preparedness for Home Health Agencies.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on document review and staff interview it was determined the agency failed to maintain documented evidence of the staff’s knowledge of the agency’s emergency preparedness plan. The agency's emergency preparedness plan was reviewed in the agency on 06/29/2022. The plan failed to include documented evidence of the staff’s ability to demonstrate knowledge of the agency emergency preparedness plan. On 06/29/2022 at 12:00 pm the Medical Facilities Inspector (MFI) requested any documentation that demonstrated the employee’s knowledge on the emergency preparedness plan. The Administrator stated they don’t do quizzes or anything to test the staff’s knowledge but the employees participate in the agency's emergency preparedness drills. The MFI requested to see a sign in sheet. The Administrator stated, “There's not a sign in sheet”. The failure to maintain documentation of the staff’s knowledge of the agency’s emergency plan was acknowledged by the Administrator and the Alternate Administrator during the review of the agency’s emergency preparedness plan and again during the exit conference conducted in the agency on 06/29/2022.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on June 27- 29, 2022 by two (2) Medical Facilities Inspectors from the Virginia Department of Health Office of Licensure and Certification. The agency reported 1103 unduplicated admissions during the last 12 months. In conjunction with the survey, the following were reviewed, the clinical records of (18) patients, (13) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, and the vaccination rule. Seven (7) home visits and multiple staff interviews were also 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 a 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 or primary care practitioner within 5 business days from the date of the final visit for four (4) of five (5) closed clinical records reviewed in the survey sample. (Clinical record #'s 9, 10, 11 and 12). The findings: Five (5) closed, electronic clinical records were reviewed both onsite and offsite in read only mode from June 28 through June 29, 2022. 1. The clinical record for patient #9 was reviewed for the certification period of 03/19/2022 to 05/17/2022. The record revealed that the patient was discharged from the agency on 04/22/2022. Per fax confirmation, the discharge summary was not sent to the physician until 05/02/2022. 2. The clinical record for patient #10 was reviewed for the certification period of 02/03/2022 to 04/03/2022. The record revealed that the patient was discharged from the agency on 03/02/2022. The clinical record failed to contain documented evidence that a discharge summary was sent to the primary physician. On 06/28/2022 at 3:15 PM the Alternate Administrator confirmed the agency failed to send a discharge summary to the primary physician and stated, I don't see it anywhere, it is not on the z drive and no fax confirmation. 3. The clinical record for patient #11 was reviewed for the certification period of 04/30/2022 to 06/28/2022. The record revealed that the patient was discharged from the agency on 06/07/2022. Per fax confirmation the discharge summary was not sent to the physician until 06/17/2022. 4. The clinical record for patient #12 was reviewed for the certification period of 04/29/2022 to 06/27/2022. The record revealed that the patient was discharged from the agency on 05/24/2022. No discharge summary was sent to the primary physician. Per fax confirmation the discharge summary was not sent to the physician until 06/03/2022. The lack of providing a discharge summary within 5 business days of the patient's discharge was acknowledged prior to and during the exit conference with the Administrator and the Alternate Administrator on 06/29/2022.