Every finding on record at Adoration Home Health Care Virginia, LLC

An unannounced on-site complaint investigation was conducted on 09/03/2025. Standard level deficiencies to the Medicare Conditions of Participation were identified.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the agency failed to notify the representative/caregiver of changes to the plan of care for 1 of 3 patients with changes to the plan of care. (patient #1) Findings included: A policy, Coordination of Care (revised 10/19/2022) received on 09/03/2025 at 12:08 PM from the branch director stated, “All personnel involved in the patient’s care are responsible for coordinating care… Coordinating care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s)…” Patient #1 was admitted on 03/05/2025 with diagnoses of pressure ulcer (wound) of sacral region, stage 3 (full thickness skin loss), dementia (loss of memory, and other thinking abilities), and vascular dementia (brain damage caused by a stroke). Patient #1 was a resident of an assisted living facility. The plan of care for 03/05/2028-5/03/2025 included orders for skilled nurse visits 2 times a week for 2 weeks, 3 times a week for 8 weeks with 3 PRN (as needed) and occupational therapy (OT) visits 1 time a week for 1 week and 1 time a week for 4 weeks. Review of the clinical record revealed that on 03/02/2025 registered nurse #7 documented the surrogate decision maker: “[daughter’s name], daughter, POA [power of attorney].” Further review of the clinical record found the following: 1. On 03/12/2025 OT #2 documented an evaluation that included implementing an OT plan of care. There was no documentation that the patient’s daughter was notified of the evaluation or changes to the plan of care. 2. On 03/12/2025 licensed practical nurse (LPN) #3 documented, “Wound to inner right greater toe. Wound is fully intact with black necrotic [tissue death] tissue… Wound to left ankle. Full thickness…” There was no documentation that the patient’s daughter was notified about the new wounds. 3. On 03/19/2025 LPN #3 documented, “RT [right] ant [anterior] lateral big toe wound has S/S [signs/symptoms] of possible infection… faint odor noted… large amount of purulent [drainage produced by an infection] …” There was no documentation that the patient’s daughter was notified. 4. On 03/28/2025 LPN #3 documented, “Tonight will be her last dose of ABX [antibiotic]…” There was no documentation of the patient’s daughter being notified of the new medication. OT #2 was not available for an interview. An interview conducted on 09/03/2025 at 12:51 PM LPN #3 revealed that LPN #3 communicated only with the assisted living facility staff and that normally they would contact the family/POA when a patient’s condition changes. During an interview conducted on 09/03/2025 at 11:53 AM the branch director stated, “We communicate with the POA as we need to; change of condition, changes in wounds, and any signs or symptoms of infection, and any changes to the plan of care.”