Every finding on record at Alternate Solutions Home Health-Fairfax

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on August 29-September 1, 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 to be in compliance with 42 CFR 484.102 the Conditions of Participation: Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency August 29-September 1, 2022 by two Medical Facilities Inspectors from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 4,938 unduplicated admissions for the past twelve (12) months. In conjunction with the survey the following were reviewed, (17) clinical records, (25) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, vaccination rule. Seven (7) home visits and multiple staff interviews were also conducted. The agency was found to be out of compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. Deficiencies were identified and cited in this report.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on a review of the agency's admission packet and staff interview, it was determined the agency failed to provide the contact information for the correct HHA (home health agency) Administrator in order to receive complaints. The findings: The agency's admission packet was reviewed in the agency on 8/30/2022. The packet contained the name and contact information for the agency's Administrator that was not on the agency's organization chart or recorded during the entrance interview of 8/29/2022. On 8/31/2022 at 9 AM the Medical Facilities Inspector asked the interim Administrator who was the person listed in the Admission packet as the administrator. The interim Administrator stated, she left the agency after March of this year. On 8/31/2022 during a teleconference meeting with the agency's Regulatory Compliance Manager, the MFI reviewed the name in the admission packet, the Regulatory Compliance Manager stated the name in the packet was the previous Administrator who left the agency June of 2022, and the agency is printing new packets with the correct name.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on a review of clinical records it was determined the agency failed to ensure patients were informed about and consented to the frequency of proposed visits in advance of starting care for four (4) of (17) patients in the survey sample (Clinical records #'s: 3, 13, 15 and 16). The findings: Seventeen electronic clinical records were reviewed in read only mode August 29-31, 2022. 1. The informed consent signed at the time of admission and prior to services being provided for patient #3 with a start of care date of 8/16/2022 failed to contain documentation of the frequency of Skilled Nursing, Home Health Aide, Speech Language Pathologist, Physical Therapy and Occupation Therapy services the patient would be receiving. 2. The informed consent signed at the time of admission and prior to services being provided for patient #13 with a start of care date of 4/18/2022 failed to contain documentation of the frequency of Skilled Nursing services the patient would be receiving. 3. The informed consent signed at the time of admission and prior to services being provided for patient #15 with a start of care date of 8/05/2022 failed to contain documentation of the frequency of Physical Therapy and Occupation Therapy services the patient would be receiving. 4. The informed consent signed at the time of admission and prior to services being provided for patient #16 with a start of care date of 8/23/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. The lack of documentation at the time of admission and prior to services being provided regarding the frequency of services to be provided was reviewed with the Interim Administrator, Director of Nursing and the Regulatory Compliance Manager prior to and during the exit conference on 9/01/2022

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review, staff interview and patient/caregiver interview, it was determined the agency failed to ensure accurate and complete medication lists were documented in three (3) of (17) clinical records reviewed in the survey sample (clinical record #'s 2, 5, and 17). The findings: Seventeen electronic clinical records were reviewed in read only mode August 29-31, 2022. The clinical record for patient #2 was reviewed for the period of 8/04/2022 to 10/02/2022. The clinical record contained a skilled nursing visit on 8/18/2022 that documented the patient's wrist was relieved by pain medication. The medication list was reviewed and did not contain pain medication. On 8/30/2022 the Medical Facilities Inspector (MFI) reviewed the medication list with the Director of Nursing (DON) and requested an interview with the skilled nurse. The skilled nurse did not call or present themselves to the MFI for an interview. The MFI contacted the patient via telephone call on 8/31/2022 at 11:48 AM. The patient reported no pain medications but had requested extra strength Tylenol for wrist pain. The DON was notified of this request. 2. The clinical record for patient #5 was reviewed for the period of 7/29/2022 to 9/26/2022. The clinical record contained an occupational therapy visit on 8/11/2022 that documented the patient's right leg had pain due to Gout and took additional pain medication as prescribed by the doctor. The medication list was reviewed and did not list any pain medication. On 8/31/2022 the MFI reviewed the medication list with the DON and requested an interview with the occupational therapist. The occupational therapist called the MFI on 8/31/2022 and concluded the pain medication may have been Colchicine. The MFI contacted the patient's spouse via telephone on 8/31/2022 at 12 PM. The patient's spouse reported the patient sometimes takes over the counter medication such as Ibuprofen, Aleve or Tylenol as needed for pain. 3. The clinical record for patient #14 was reviewed for the period of 8/09/2022 to 10/17/2022. The clinical record contained a physical therapy visit on 8/16/2022 that documented the patient's back, shoulder, knee, ankle/foot had pain and was relieved by pain medication. The medication list in the record was reviewed and did not contain any pain medication. The MFI contacted the patient's caregiver via telephone on 8/31/2022 at 11:27 AM. The patient's caregiver reported the patient takes Advil as needed for pain morning, afternoon and night time. The failure to update each patient's medication profile was reviewed with the Interim Administrator, Director of Nursing and the Regulatory Compliance Manager prior to and during the exit conference on 9/01/2022

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure each patient received home health services as ordered by the physician in the patient's individualized plan of care for two (2) of seventeen (17) clinical records in the survey sample (Clinical records #'s 1 and 11) The findings: Seventeen electronic clinical records were reviewed in read only mode August 29-31, 2022. The clinical record of patient #1 was reviewed for the certification period 8/11/2022 to 10/09/2022. According to patient #1's plan of care (POC) the patient was to receive physical therapy one (1) time a week for two (2) weeks. The clinical record failed to contain documentation of a physical therapy visit for week two or an explanation as to why a visit was not conducted as ordered. On 8/30/2022 the agency's Clinical Field Staff Liaison provided the Medical Facilities Inspector (MFI) with a document that read as follows: "Problem: 2nd PT (physical therapy) visit was never performed by assigned clinician (physical therapist name) as it is showing on clinician as LATE from 8/19/2022". On 8/31/2022 at 2:15 PM, the interim Manager stated, I think it is a missed visit that has not processed. In addition, the clinical record contained no further documentation since the last visit of an occupational therapist on 8/12/2022. The patient did not receive any further visits from week one and there was no discharge information. On 8/30/2022 the agency's Clinical Field Staff Liaison provided the MFI with a document that read as follows: "Patient was referred by agency as a charity case with 2 PT visits and 1 OT (occupational therapy) visit". On 8/31/2022, the MFI requested the status of patient #1, however the interim Administrator and Regulatory Compliance Manager failed to provide the MFI prior to the exit conference with the status of the patient, active or discharged. 2. The clinical record of patient #11 was reviewed for the certification period 7/12/2022 to 9/09/2022. According to patient #1's plan of care (POC) the patient was to receive skilled nurse services one (1) time a week for seven (7) weeks beginning week three. The clinical record failed to contain documentation of a skilled nurse visit for week six (8/14-20/2022), or an explanation as to why a visit was not conducted as ordered. On 8/31/2022 the interim Administrator stated, the missed visit probably has not been processed. The above noted findings were reviewed and acknowledged by the Director of Nursing, interim Administrator and the Regulatory Compliance Manager on 9/01/2021.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on interviews and a review of agency documentation it was determined agency staff failed to develop and implement policies and procedures regarding a COVID-19 contingency plan for unvaccinated staff. The findings: On August 30-31, 2022 the agency's policy and procedure binder labeled "infection control" was reviewed. The MFI (Medical Facilities Inspector) noted there was no documentation of a contingency plan for staff who were not fully vaccinated. On August 30, 2022 at 9:45 AM the MFI requested the agency's contingency plan. The interim Administrator stated, we don't have that...that is something as a corporation we need to work on". On August 31, 2022 at 10:30 AM the interim Administrator stated, we are not discriminating between exempt and vaccinated staff.

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 transfer summary within 2 business days of becoming aware of an unplanned transfer for two (2) of five (5) closed clinical records reviewed in the survey sample. (Clinical record #'s 6 and 7). The findings: Seventeen electronic clinical records were reviewed in read only mode August 29-31, 2022. 1. The clinical record for patient #6 was reviewed for the certification period of 7/09/2022 to 9/06/2022. The record revealed that the patient was transferred from the agency on 7/27/2022. The transfer summary was sent to the primary physician on 8/11/2022 (15 days later). 2. The clinical record for patient #7 was reviewed for the certification period of 05/24/2022 to 7/22/2022. The record revealed that the patient was transferred from the agency on 5/31/2022. No transfer summary was sent to the primary physician. On 8/31/2022 at 1:10 PM the interim Administrator stated, we don't have the fax confirmation for where that was sent. The lack of providing a patient's transfer summary within 2 business days was acknowledged prior to and during the exit conference with the Director of Nursing, interim Administrator and the Regulatory Compliance Manager on 9/01/2022.