Every finding on record at Adoration Home Health Care Virginia LLC

An unannounced, onsite complaint investigation was conducted on 12/18/23. The allegation related to Patient Rights was substantiated with deficiencies. The complaint related to Quality of Care was unsubstantiated without deficiencies.

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interview, the agency failed to document the resolution of a complaint for 1 of 1 patient voicing a complaint [#1]. The findings included: The policy, Complaint Resolution [1/4/23], was provided by the Sr Director of Regional Operations on 12/18/23 at approximately 11:15 am. The policy stated, "The agency should have systems in place to record, track and investigate all complaints…The agency must document both the existence of the complaint and the resolution of the complaint…” Patient # 1 had a Start of Care date of 11/26/23 with an admitting diagnosis of unspecified dementia. Review of the Plan of Care for the certification period 11/26/23-1/24/23 included orders for SN [skilled nursing] 1 time a week for 3 weeks, 1 time every 2 weeks for 4 weeks; home health aide 2 times a week for 4 weeks; PT [physical therapy] 1 time a week for 9 weeks; OT [occupational therapy] beginning 12/3/23[MD was informed of late evaluation] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 1 week, 2 times a week for 1 week. Review of the clinical record revealed a coordination note dated 12/6/23 by RN # 1. The note stated,” I spoke to patient’s spouse. She is very upset with not seeing anyone [therapy] but that one-time last week. She feels he needs more therapy that that. She doesn’t understand why no one has called her…” Review of the clinical record and agency documents revealed no documentation related to resolution or any follow-up related to the complaint. During an interview with the Sr. Director of Regional Operations on 12/18/23 at approximately 3pm, it was confirmed the agency failed to document any follow-up related to the complaint.

An unannounced complaint investigation was conducted on 02/01/2021. The complaint was substantiated. Deficiences to the Medicare Conditions of Participation were identified. NC00173262 ABH

Document complaint and resolution CFR(s): 484.50(e)(1)(ii) (ii) Document both the existence of the complaint and the resolution of the complaint; and This ELEMENT is not met as evidenced by: Based on agency policy and procedure, complaint log review, and staff interview the agency failed to document a patient/caregiver complaint for 1 of 3 patients (#1). Findings included: A policy, "Patient Incident Policy" revised 02/21, was received from Employee #1 on 02/01/21 at 12:533p.m. The policy stated, "to provide accurate documentation of all complaints, incidents and occurrences voiced by members of the general and medial communities (i.e., patients, customers, caregivers, physicians, referral sources, employees, etc.)". The complaint log was reviewed with no documented complaints from Patient/Caregiver #1. Interview with Employee #1 on 02/01/21 at 12:53 p.m. revealed " yes, it should have been logged as a complaint per our policy".

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on agency policy and procedure, clinical record review, and staff interview the agency failed to follow the physician's order related to skilled nursing visits for 1 of 3 patients with a wound (#1). Findings included: A policy, "Plan of Care" revised 9/20, was received from Employee #1 on 02/01/21 at 12:58 p.m. The policy stated, "services, treatment, and care relative to the needs of the patient as identified in the plan of care ....shall be provided in a safe, effective manner, coordinated among those responsible in the continuum of care ... the plan of care developed in consultation with the agency staff covers all pertinent diagnoses included ... frequency of visits". Patient #1 had a start of care (SOC) date of 12/28/20 and included diagnoses of encounter for surgical aftercare following surgery of the cardiovascular system; heart failure, unspecified; chronic kidney disease, stage 2; and unspecified atrial fibrillation. Skilled nursing visits were ordered for 3 times a week for 2 weeks, with 2 prn (as needed). Skilled nursing orders were to instruct patient on signs/symptoms of wound infection to report to the physician, to include increased temperature of greater than 100.5, chills, increase in drainage, foul odor, redness, unrelieved pain of greater than 5 on 0-10 scale, and any other significant change. SN to instruct patient and caregiver on high protein diet to promote wound healing. Skilled nurse to instruct patient and caregiver on measures to control CHF (congestive heart failure). Review of the SN notes revealed visits were completed on 12/28/20 and 12/31/20. Missed visits were completed for the following visits: 01/02/21, 01/04/21, and 01/06/21, per the orders 3 skilled nursing visits should have been completed for the week of 01/04/21 only 2 missed visits are in the record for that week. Further review of the record revealed a non-billable discharge oasis was completed on 01/11/21. A discharge summary was not found in the record, nor any documentation reflecting why the patient was discharged. Interview with Employee #2 on 02/01/21 at 11:58 a.m. revealed " documentation in record is poor, a lot of communication went back and forth thru emails regarding staff and test results, communication with sales team and the wife eventually requested discharged from the agency".