Every finding on record at Avalon in Home Nursing and Rehabilitation LLC

An unannounced Home Health Medicare Complaint Survey (ID# 110685) was conducted at the above noted agency October 28, 2024 to October 29, 2024 by one (1) Medical Facilities Inspector from the Virginia Department of Health, Office of Licensure and Certification. The agency was found not to be in compliance with the Federal requirements of 42 CFR 484, the Medicare Conditions of Participation of Home Health Agencies. A deficiency was cited within this report.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on personnel file review, and interviews, it was determined the agency failed to immediately remove a staff member from patient care due to allegations of misconduct related to abuse. Specifically, an employee of the agency was not removed from patient care for (19) days after an allegation of sexual misconduct of a patient for one (1) of six (6) patients in the survey sample (Clinical record for Patient #1). Findings: The clinical record for Patient #1 was reviewed for the period of July 19, 2024 to July 31, 2024. The clinical record indicated Staff Member #3 was the only visiting staff member. The clinical record did not indicate any documentation of inappropriate or sexual misconduct. Patient #1 was discharged from the agency on July 31, 2024 by Staff Member #3 with all goals met for therapy. On October 28, 2024 at 3:48 PM the Medical Facilities Inspector (MFI) conducted an interview with Staff Member #1. Staff Member #1 revealed that Staff Member #3 usually makes all therapy visits as in (name redacted) Patient #1’s case due to it is only two (2) PTA’s (Physical Therapy Assistant) available in that service area and Staff Member #3 prefers not to supervise the PTA’s. The personnel file for Staff Member #3 was reviewed on October 28, 2024. The personnel file contained a typed and signed letter by Staff Member #3 dated October 12, 2024. The letter indicated Staff Member #3’s attestation of the events on July 31, 2024 as discharging Patient #1 from therapy, hugging, and kissing. Staff Member #3 indicated they both sat on the couch and continued kissing, leading to kiss Patient #1’s (part of body redacted) and touched their (genitalia redacted). Patient #1 asked me if we could stop and I stopped right away. The following afternoon Patient #1 called and Staff Member #3 called Patient #1 back. Staff Member indicated Patient #1 sounded mad and upset asking multiple times why I kissed “them”. Staff Member #3 indicated they were sorry if “their” feelings were hurt and never forced “them” to do anything, and I even asked “them” multiple times if “they” was ok, which “they” replied am fine. The call ended with Patient #1 telling me to not call “them” back ever again. I did not contact “them” again. Staff Member #3’s “Disciplinary Action for Unprofessional Conduct” was dated October 16, 2024 with an indefinite suspension. Staff Member #3’s personnel file was reviewed further for any previous conviction data as follows: "Criminal Record Check” of February 24, 2020 contained no Virginia Conviction Data or no Virginia Sex Offender Registration Record. “A National Sex Offender Public Website from The United States of Department of Justice” contained no records from Virginia dated February 27, 2020. The “Virginia Department of Health Professions License Lookup” indicated a current active license status with no additional public information. The personnel file was reviewed for agency policies and procedures as follows: Staff Member #3 signed and dated the “Acknowledgement of Mandated Reporter Status” on January 22, 2020. A “Code of Business Ethics and Compliance” revised on August 01, 2023 and signed by Staff Member #3 on September 03, 2023. On September 03, 2023, Staff Member #3 signed the “Sexual Harassment and Discrimination” revised on March 23, 2023. An “Independent Contractor Service Agreement “revised on July 12, 2023 and signed by Staff Member #3. The MFI reviewed the agency’s policy and procedures to ensure the agency has a system in place to protect patients from abuse, neglect and misappropriation of property from staff as follows: -“Acknowledgement of Mandated Reporter Status” read in part as: I am required to report or cause a report to be made to the Virginia Adult Protective Services (APS) either by calling APS or the appropriate local department of social services whenever I have reasonable cause to suspect that an adult aged 60 or over or an incapacitated adult aged 18 and over who is known to me in my professional or official capacity may be abused, neglected, or exploited. I understand that I must follow the reporting protocol, if any, to my employer, but my employer may not prohibit me from reporting directly to APS. -“Patient Visit Rules” that read in part as: While it is impossible to list every type of behavior that may be deemed a serious offense, these visit rules include examples that may result in disciplinary actions up to including termination of contract. Any willful act or conduct that jeopardizes the welfare of patient’s. -“Code of Business Ethics and Compliance” revised on August 01, 2023 read in part as follows: 18. It is a violation of this Code for employees, independent contractors and or vendors not to report a violation of the Code or to fail to report any wrongdoing or suspected wrongdoing. 19. It is (agency name redacted) policy to promptly and thoroughly investigate reports of wrongdoing or suspected wrongdoing or violations of this Code. Employees must cooperate with these investigations 20. Employees, contractors, or vendors who violate the Code or commit illegal acts are subject to discipline up to and including dismissal. - “Sexual Harassment and Discrimination” revised on March 23, 2023 that read in part as: Each employee is responsible for creating an environment free from harassing conduct. Harassment can be either sexual or non-sexual conduct that is offensive, fails to respect the rights of others or interferes with work. Examples of sexual harassment include, but not limited to the following: Unwanted or unnecessary physical contact, sexual touching, brushing up against another in a sexual manner, graphic or sexually suggestive gestures, cornering, pinching, grabbing, kissing, or fondling. Procedure-2. Any employee who violates the policy against sexual harassment, or encourages another to violate the policy, will be subjected to appropriate disciplinary action depending on the severity and type of violating behavior, up to and including discharge. -“Independent Contractor Service Agreement “revised on July 12, 2023 read in part as: c. Contractor shall comply with all policies, procedures, rules and regulations, both written and oral, as communicated by the Company from time-to-time d. Contractor shall render reasonable and appropriate treatment to every patient presented, consistent with professional standards and within Therapist scope of practice. 17. Contractor acknowledges that (agency name) is required by statue to report to the Virginia Department of Health Professions certain conduct and/or disciplinary action with respect to any Contractor subject to regulation by the health regulatory board. The above policies and procedures indicated the agency has a system in place to protect patients from abuse, neglect and misappropriation of property from staff. On October 28, 2024 at 4 PM the MFI conducted an interview with Staff Member #4. Staff Member #4 revealed that Patient #1 did not lodge a complaint with the agency but was contacted by the County Police Detective (name redacted). The Detective reported the complaint to the agency on September 27, 2024. Staff Member #4’s interview revealed Staff Member #3’s alleged sexual assault was reported to the agency on September 27, 2024 and Staff Member #3 was suspended from the agency on October 16, 2024. The agency did not immediately remove Staff Member #3 from patient care until (19) days after the allegation of sexual misconduct.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on review of personnel file, agency policies and procedures and the Unprofessional Conduct of the Code of Virginia, it was determined that the agency Staff Member #3 failed to provide accepted professional standards of practice in one (1) of six (6) clinical records in the survey sample (Clinical record for Patient #1). Findings: The personnel file for Staff Member #3 was reviewed on October 28, 2024. The personnel file contained a typed and signed letter by Staff Member #3 dated October 12, 2024. The letter indicated Staff Member #3’s attestation of the events on July 31, 2024 as discharging Patient #1 from therapy, hugging, and kissing. Staff Member #3 indicated they both sat on the couch and continued kissing, leading to kiss Patient #1’s (part of body redacted) and touched their (genitalia redacted). Patient #1 asked me if we could stop and I stopped right away. The following afternoon Patient #1 called and Staff Member #3 called Patient #1 back. Staff Member indicated Patient #1 sounded mad and upset asking multiple times why I kissed “them”. Staff Member #3 indicated they were sorry if “their” feelings were hurt and never forced “them” to do anything, and I even asked “them” multiple times if “they” was ok, which “they” replied am fine. The call ended with Patient #1 telling me to not call “them” back ever again. I did not contact “them” again. Staff Member #3’s “Disciplinary Action for Unprofessional Conduct” was dated October 16, 2024 with an indefinite suspension. The personnel file was reviewed for agency policies and procedures as follows: Staff Member #3 signed and dated the “Acknowledgement of Mandated Reporter Status” on January 22, 2020. The Acknowledgment read in part as: I am required to report or cause a report to be made to the Virginia Adult Protective Services (APS) either by calling APS or the appropriate local department of social services whenever I have reasonable cause to suspect that an adult aged 60 or over or an incapacitated adult aged 18 and over who is known to me in my professional or official capacity may be abused, neglected, or exploited. I understand that I must follow the reporting protocol, if any, to my employer, but my employer may not prohibit me from reporting directly to APS. Staff Member #3 signed the Physical Therapist job description on January 22, 2020 that read in part as: Is responsible for adhering to all practice standards as they apply to patient care. The personnel file also contained a “Patient Visit Rules” and signed on January 22, 2020, that read in part as: While it is impossible to list every type of behavior that may be deemed a serious offense, these visit rules include examples that may result in disciplinary actions up to including termination of contract. Any willful act or conduct that jeopardizes the welfare of patient’s. A “Code of Business Ethics and Compliance” revised on August 01, 2023 and signed by Staff Member #3 on September 03, 2023 read in part as follows: 18. It is a violation of this Code for employees, independent contractors and or vendors not to report a violation of the Code or to fail to report any wrongdoing or suspected wrongdoing. 19. It is (agency name redacted) policy to promptly and thoroughly investigate reports of wrongdoing or suspected wrongdoing or violations of this Code. Employees must cooperate with these investigations 20. Employees, contractors, or vendors who violate the Code or commit illegal acts are subject to discipline up to and including dismissal. On September 03, 2023, Staff Member #3 signed the “Sexual Harassment and Discrimination” revised on March 23, 2023 that read in part as: Each employee is responsible for creating an environment free from harassing conduct. Harassment can be either sexual or non-sexual conduct that is offensive, fails to respect the rights of others or interferes with work. Examples of sexual harassment include, but not limited to the following: Unwanted or unnecessary physical contact, sexual touching, brushing up against another in a sexual manner, graphic or sexually suggestive gestures, cornering, pinching, grabbing, kissing, or fondling. Procedure-2. Any employee who violates the policy against sexual harassment, or encourages another to violate the policy, will be subjected to appropriate disciplinary action depending on the severity and type of violating behavior, up to and including discharge. In addition, an “Independent Contractor Service Agreement “revised on July 12, 2023 and signed by Staff Member #3 read in part as: c. Contractor shall comply with all policies, procedures, rules and regulations, both written and oral, as communicated by the Company from time-to-time d. Contractor shall render reasonable and appropriate treatment to every patient presented, consistent with professional standards and within Therapist scope of practice. 17. Contractor acknowledges that (agency name) is required by statue to report to the Virginia Department of Health Professions certain conduct and/or disciplinary action with respect to any Contractor subject to regulation by the health regulatory board. According to “§ 54.1-3483 Unprofessional conduct of the Code of Virginia” sexual contact includes, but is not limited to, sexual behavior or verbal or physical behavior that: 1. May reasonably be interpreted as intended for the sexual arousal or gratification of the practitioner, the patient, or both; or 2. May reasonably be interpreted as romantic involvement with a patient regardless of whether such involvement occurs in the professional setting or outside of it. 10. Engages in sexual contact with a patient concurrent with and by virtue of the practitioner/patient relationship or otherwise engages at any time during the course of the practitioner/patient relationship in conduct of a sexual nature that a reasonable patient would consider lewd and offensive. (https://law.lis.virginia.gov/vacode/54.1-3483/). The personnel file contained Staff Member #3’s attestation of events that indicated sexual misconduct; an indefinite suspension from the agency on October 16, 2024; all policies and procedures were signed during the date of hire (January 22, 2020) and ongoing until the suspension of October 16, 2024 regarding unacceptable behaviors, professional standards including Mandated Reporter Status, Code of Business Ethics and Compliance and Sexual Harassment and Discrimination. Staff Member #3 failed to follow the agency’s policies and procedures regarding sexual misconduct.

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted September 19-21, 2022 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.

An unannounced Medicare Medicaid Home Health Agency recertification survey was conducted September 19-21, 2022 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 911 unduplicated admissions in the last twelve (12) months with an active census of 221 patients. The following were completed/reviewed in conjunction with the survey: Seven (7) home visits, seventeen (17) clinical records, ten (10) personnel files, review of selected policies and procedures, the agency's complaint log, emergency preparedness plan, and Covid vaccination records. Interviews were also conducted. Deficiencies were identified and cited in this report. The agency was found to be out of compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs).

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 staff interview and document review it was determined agency staff failed to ensure each patient participated in and was informed of the care in advance of treatment being furnished to include the visit frequency for all disciplines in nine (9) of seventeen (17) clinical records reviewed in the survey sample (clinical records #1, 2, 4, 5, 6, 7, 8, 14, and 17). The findings were: The electronic clinical records were reviewed from 9/19/2022 through 9/21/2022 in read-only mode. The clinical records contained consent forms which list each discipline and contained an area for the proposed frequency for each discipline to be written in by the admitting clinician. 1. Clinical record #1 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing and physicial therapy) and their visit frequency. 2. Clinical record #2 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing and physicial therapy) and their visit frequency. 3. Clinical record #4 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing, home health aide and physicial therapy) and their visit frequency. 4. Clinical record #5 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing) and their visit frequency. 5. Clinical record #6 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing and physicial therapy) and their visit frequency. 6. Clinical record #7 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing) and their visit frequency. 7. Clinical record #8 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing, occupational therapy and physicial therapy) and their visit frequency. 8. Clinical record #14 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing) and their visit frequency. 9. Clinical record #17 contained a signed consent form however, the admitting clinician failed to document what disciplines would be visiting the patient (skilled nursing and home health aide) and their visit frequency. The findings were reviewed with the administrator, staff member #1 and the compliance officer, staff member #2 prior to and during the exit conference. Both staff members acknowledged the deficient practice.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on document review it was determined the agency failed to ensure each patient was advised in advance of providing care the extent to which payment for HHA (home health agency) services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, the charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, and the charges the individual may have to pay before care is initiated in nine (9) of seventeen (17) clinical records reviewed in the survey sample (clinical records #1, 2, 4, 5, 6, 7, 8, 14 and 15). The findings were: The electronic clinical records were reviewed from 9/19/2022 through 9/21/2022 in read-only mode. The clinical records contained a photo copy of the consent for treatment. The consent contained a section with all disciplines listed, the rates for each discipline and a blank space for the agency staff to write in the patient rate (the amount the patient would pay) titled "your rate". The staff failed to fill in the space with a rate (dollar amount) or mark the space as zero in nine (9) of the seventeen (17) clinical records reviewed (#1, 2, 4, 5, 6, 7, 8, 14 and 15). The findings were reviewed with the administrator, staff member #1 and the compliance officer, staff member #2 prior to and during the exit conference. Both staff acknowledged the deficient practice.

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 or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview it was determined the agency's staff failed to ensure plans of care contained all required elements. Specifically, the plan of care for one patient failed to contain information about a foley catheter and four (4) clinical records failed to contain the site of wounds requiring wound care (clinical records #2, 6, 7, and 8). The findings were. The electronic records were reviewed in read-only mode from 9/19/2022 through 9/21/2022. 1. Clinical record #2 was reviewed for the certification period of 8/4/2022 through 10/02/2022. The plan of care contained orders to assess the wound with each dressing change. The orders did not have a location listed for the wound. A review of the skilled nursing and physicial therapy notes revealed the patient had a surgical wound of the right knee. 2. Clinical record #6 was reviewd for the certification period of 8/11/2022 through 10/09/2022. The plan of care contained orders to "perform wound care as follows" with a list of wound care instructions. The orders did not have a location listed for the wound. A review of the skilled nursing notes revealed the patient had an abscess of the perineum. 3. Clinical record #7 was reviewed for the certification period of 7/21/2022 through 9/18/2022. The plan of care contained orders to "clean wound as follows" with a list of instructions for wound care. The orders did not have a location listed for the wound. A review of skilled nursing notes revealed the patient had a wound in the right groin. In addition, a review of the clinical record revealed the patient had a foley catheter (a tube that drains urine from the bladder) present on admission that was not listed on the plan of care. A review of nursing notes revealed no documented care or changing of the foley by agency staff. 4. Clinical record # 8 was reviewed for the certification period of 8/4/2022 through 10/2/2022. The plan of care contained orders for "wound care as follows" with a list of wound care instructions. The orders did not have a location listed for the wound. A review of the nursing notes revealed the patient had a wound on the left knee. The findings were reviewed with the administrator, staff member #1 prior to and during the exit conference.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations and interviews it was determined the agency staff failed to follow infection control guidelines when performing wound care for one (1) of four (4) patients who had wound care observed during home visits (clinical record #6). Specifically the nurse failed to change gloves and perform hand hygiene when going from a dirty to clean area during wound care. The findings were: A home visit was conducted with the skilled nurse (staff member #5) on 9/21/2022 at 9:00 AM to patient #6 in the survey sample. The skilled nurse, staff member #5 was observed multiple times throughout the wound care, removing dirty gloves and doning clean gloves. At no time during the glove change did the nurse performing hand hygiene, At the conclusion of the visit, the skilled nurse was interviewed about hand hygiene. The nurse stated "I always wash my hands at the beginning and end of wound care, is that not right?" A review of the agency policy titled "Hand Hygiene Policy and Compliance Program" states in part: The agency will follow the Centers for Disease Control and Prevention guidelines for hand hygiene. Recommendations: after removing gloves. Fundamentals of Nursing Mosby, Potter and Perry, 7th Edition St. Louis Missouri, page 645 states in part: modes of transmission for infection are indirect contact-personal contact of susceptible host with contaminated inanimate object (e.g.,needles or sharp objects, dressings, environment). In this case, the gloves would have been contaminated after touching the wound and gloves should have been changed each time with hand hygiene performed when going from a dirty to clean area. Page #655 goes on to discuss medical asepsis or clean technique procedures are used to reduce the number of organisms present and prevent the transfer of organisms. The findings were reviewed with the administrator, staff member #4 prior to and during the exit conference.