Every finding on record at Blue Ridge Home Health Care

An unannounced Home Health Agency recertification survey was conducted on February 15 -17, 2023 and February 21, 2023, 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 Recertification survey was conducted at the above noted agency February 15-17, 2023 and February 21, 2023 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 1,081 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, (17) clinical records, vaccination rule and (15) personnel files were reviewed. Seven (7) home visits and were 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.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, it was determined the agency's professional staff failed to promptly alert the patient's physician to any changes that suggest a need to alter the patient's plan of care for one (1) of (17) clinical records in the survey sample (Clinical record #7). The findings: Seventeen (17) clinical records were reviewed in the agency on 02/17/2023 and 02/21/2023 with the Alternate Administrator as the electronic health record navigator with the following findings: The clinical record for patient #7 was reviewed for the certification period of 07/15/2022 to 09/12/2022. The plan of care contained physician orders for vital sign parameters that read: Notify MD (Medical Doctor) if HR (Heart Rate) >110 (more than 110 heart beats per minute). The clinical record failed to contain documentation of notifying the physician of the patient's heart rate over 110. Specific details: 08/15/2022 - HR by Skilled Nurse (SN) of 122. The failure to alert the physician to changes that suggest a need to alter the plan of care was reviewed with the Alternate Administrator during the clinical record review and the exit conference with the Administrator conducted on 02/21/2023.

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 discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit for one (1) of two (2) closed clinical records that was applicable for a discharge summary reviewed in the survey sample. (Clinical record #7). The findings: Five (5) closed clinical records were reviewed in the agency on 02/17/2023 and 02/21/2023 with the Alternate Administrator as electronic health record navigator with the following findings: The clinical record for patient #7 was reviewed for the certification period of 07/15/2022 to 09/12/2022. The clinical record revealed that the patient was discharged from the agency on 08/16/2022. The discharge summary was sent to the primary physician on 09/07/2022; 22 days later. The lack of providing a discharge summary within 5 business days of the patient's discharge prior to and during the exit conference with the Alternate Administrator and the Administrator on 02/21/2023.