Every finding on record at All Care Home Health, Inc

An unannounced Home Health Agency recertification survey was conducted on January 11-12, 2021 by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. The agency was found to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

One (1) Medical Facilities Inspector (MFI) from the Office of Licensure and Certification, Virginia Department of Health conducted a Recertification inspection at the above noted agency January 11-12, 2021. The survey occurred both onsite and remotely due to the COVID-19 Public Health Emergency. The agency reported 80 unduplicated admissions in the last 12 months. The facility was found not to be in compliance with the Federal requirements of 42 CFR 484, the Medicare Conditions of Participation of Home Health Agencies.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician may choose to include. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview it was determined the agency failed to ensure the patient's individualized plan of care included evidence the patient participated in goal setting and/or agreed with goals identified by the Home Health Agency for four (4) of eight (8) clinical records in the survey sample (Clinical records: #1, #2, #3, and #7) The findings: Seven clinical records were reviewed 1/11/2021 between the hours of 7:00 p.m. to 10:00 p.m. with read only access. The plan of care for the patients below failed to contain documented evidence the patient/caregiver participated in goal setting. 1. The clinical record for patient #1 was reviewed for the certification period of 12/11/2019 to 2/8/2020. 2. The clinical record for patient #2 was reviewed for the certification period of 10/11/2019 to 12/9/2019. 3. The clinical record for patient #3 was reviewed for the certification period of 12/30/2020 to 2/27/2021. 4. The clinical record for patient #7 was reviewed for the certification period of 12/1/2020 to 1/29/2021. On 1/11/2021 at 1:00 p.m. and 1/12/2020 at 2:00 p.m. the MFI asked the Administrator to show the patient/caregiver stated goals on the plans of care. The Administrator was unable to provide the MFI with patient stated goals for the above clinical records. The above noted findings regarding the lack of the required content of the plan of care was reviewed with the Agency Owner, Administrator and Clinical Manager prior to and during the exit conference conducted on 1/12/2021 at 3:00 p.m.