Every finding on record at Adoration Home Health Care Virginia LLC

An onsite complaint investigation was conducted September 25, 2023-September 26, 2023. The allegations were unsubstantiated. A deficiency to the Medicare Conditions of Participation was identified. CI 100895

Investigate complaints made by patient CFR(s): 484.50(e)(1)(i) (i) Investigate complaints made by a patient, the patient's representative (if any), and the patient's caregivers and family, including, but not limited to, the following topics: This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to investigate and resolve a complaint for 1 of 4 patients reviewed (#1). Findings included: A policy, “Complaint Resolution” (revised 1/4/23), was provided by the agency director on 9/26/23 at 12:15 p.m. The policy stated, “The Agency must investigate and attempt to resolve all complaints made by a patient, the patient’s representative (if any), and the patient's caregiver and family, including but not limited to…Treatment or care that is (or fails to be) furnished, is furnished inconsistently, or is furnished inappropriately…The Agency must document both the existence of the complaint and the resolution of the complaint…The Agency should be able to produce documentation for each complaint received that confirms an investigation was conducted and records the investigation findings as well as the ultimate resolution of the complaint…The supervisor or designee will follow-up with the patient/family within 24 hours of receipt of the complaint; and will conduct an investigation, communicate with the patient/family, and record the investigation findings as well as the ultimate resolution of the complaint within 5 business days of receipt of the complaint…The Agency will maintain records of grievances/complaints and their outcomes…” A policy, “Patient Rights and Responsibilities” (revised 9/8/22), was provided by the clinical manager #1 on 9/25/23 at 12:24 p.m. The policy stated, “The patient has the right to…Make complaints to the agency regarding treatment or care that is (or fails to be) furnished…” Patient #1 was admitted on 11/22/22 with diagnoses of encounter for adjustment and management of vascular access device (provides access to veins for the delivery of IV medications and/or fluids), gastroparesis (a condition that affects the normal spontaneous movement of the muscles in the stomach), and protein-calorie malnutrition. The Plan of Care (POC) for 5/21/23-7/19/23 included orders for skilled nursing visits weekly for nine weeks. The POC also included orders for nursing to obtain labs via port-a-cath (a vascular access device) monthly, perform IV site care and Huber needle (a type of needle used to access port-a-caths) change to port-a-cath weekly using sterile technique, and flush IV access with 10 ml of normal saline weekly with port-a-cath change. The patient was discharged on 7/4/23 per request. The agency received a new referral on 8/14/23. On 8/22/23, RN #3 documented, “She [Patient #1] is also refusing to allow her previous RN who covers her area to complete her admission visit-citing concerns with her previous hand hygiene and infection control. She never called and reported that concern to clinical manager or verbalize any such concern for the several months she was under her care.” There was no evidence the patient’s concerns related to hand hygiene and infection control were investigated or resolved. An interview with RN #3 at 9/26/23 at 1:37 revealed she instructed the patient to call the clinical manager. RN #3 also stated that she reported the concern to the clinical manager #4. Clinical manager #4 was unavailable for interview. An interview with the agency director on 9/26/23 at 1:40 p.m. revealed there was no evidence that the concern was investigated.