Every finding on record at Caring Nurses Advocates for Patients (Cnap)

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Virginia Department of Health, Health Facility Survey and Field Operations. An unannounced on-site Recertification Survey at the above-named Home Health Agency (HHA) from 08/18/25 to 08/19/25 resulted in a finding of no deficiency citations respective to the Emergency Preparedness Program Condition of Participation under 42 CFR 484.102.

A Recertification Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Virginia Department of Health, Health Facility Survey and Field Operations. An unannounced on-site Recertification Survey conducted at the above named Home Health Agency (HHA) from 08/18/25 to 08/19/25 resulted in a finding of substantial compliance respective to the applicable Condition of Participation (CoP) under 42 CFR 484, Subparts A through C with the following standard-level deficiencies listed below.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, interviews, and policy review, the Home Health Agency (HHA) failed to complete an initial assessment within 48 hours of the referral date, the inpatient discharge date, or the practitioner ordered start of care (SOC) date for three of six patients (Patient (P) 1, P2, and P6). The delay in the initial assessment had the potential to affect patient safety or delay identification of signs or symptoms of health concerns which could result in rehospitalization. Findings include: Review of the agency policy titled, "Patient Initial Assessments/Comprehensive Assessments," dated February 2023, revealed, "An agency that is unable to complete the initial assessment within 48 hours of referral or the patient's return home, will not request a different start of care date from the physician/practitioner to ensure compliance with the regulation or to accommodate the convenience of the Agency . . . In instances where the patient requests a delay in the start of care date, the Agency will need to contact the physician/practitioner to request a change in the start of care date and such change will be documented in the medical record . . . A RN [Registered Nurse], PT [Physical Therapist], or SLP [Speech-Language Pathologist] must conduct the initial assessment visit within 48 hours of referral, within 48 hours of the patient's return home or on the physician/practitioner ordered start of care date . . . In the absence of a physician/practitioner specified start of care date, the initial assessment visit is conducted within 48 hours of the referral . . ." 1. Review of P1's paper medical record file revealed an order written by a physician assistant on 01/23/25 showing, "At home PT 2x [two times a week] for 2 weeks then 1x [one time a week] for 4 wks [weeks]. Dx [diagnosis] Generalized weakness." Review of P1's "Home Health Certification and Plan of Care [POC]" located in the paper medical record file showed a SOC date of 04/28/23 with the "Certification Period" identified as 01/27/25 – 03/27/25. Review of P1's OASIS [Outcome and Assessment Information Set] for the "Certification Period" 01/27/25 – 03/27/25 showed the assessment was completed by PT on 01/27/25. During an interview on 08/18/25 at 10:30 AM, the Clinical Manager (CM) stated the SOC date on the POC was incorrect and was due to the patient being on unskilled personal care services with the agency prior to the referral for skilled services. The CM confirmed the SOC for skilled services was more than 48 hours after the referral. 2. Review of P2's paper medical record file revealed a referral for PT and OT (Occupational Therapy) dated 09/26/24. Review of P2's POC located in the paper medical record showed a SOC date of 10/02/24. Review of P2's OASIS located in the paper medical record showed the initial assessment was completed on 10/02/24. During an interview on 08/19/25 at 11:30 AM, the CM confirmed the initial SOC assessment was completed more than 48 hours after the referral. 3. Review of P6's paper medical record file revealed a referral dated 03/06/24 and noted an inpatient facility discharge date of 03/06/24. Review of P6's OASIS located in the paper medical record file showed the initial assessment was completed on 03/11/24. During an interview on 08/19/25 at 11:30 AM, the CM confirmed the initial SOC assessment was completed more than 48 hours after the referral.

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 record review, interview, and policy review, the Home Health Agency (HHA) failed to include in the discharge summary sent to the patient's primary care provider (PCP) all necessary information regarding the care and services the patient received for six of six patients (Patient (P) 1, P2, P3, P4, P5, and P6). The lack of medical information communicated to the primary care provider regarding the patient's home health care, response to services provided, and review of current medications had the potential to compromise the patients' health and safety. Findings include: Review of the agency policy titled, "Discharge Summary," dated February 2021, revealed, "A Discharge Summary form will be completed by the Skilled Nurse, Medical Social Worker and/or Therapist. The Discharge Summary will include, but is not limited to: Discharge date, Reason for discharge, Laboratory data, Patient's discharge condition, Types of services provided and frequency of services, Patient's outcomes in meeting goals in the plan of care, Patient/family post-discharge instructions, goals, and treatment preferences, Medications at the time of discharge." 1. Review of P1's undated "Discharge Summary," located in a paper medical file, revealed the document was addressed to P1's PCP. The information documented on the form included: "Discipline Being Discontinued: PT [Physical Therapy]" and "No further skilled care needed." The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 2. Review of P2's undated "Discharge Summary," located in a paper medical file, revealed the document was addressed to P2's PCP. The information documented on the form included: "Discipline Being Discontinued: PT" and "Patient has met all goals." The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 3. Review of P3's undated "Discharge Summary," located in a paper medical file, revealed the document was addressed to P3's PCP. The information documented on the form included: "Discipline Being Discontinued: PT, ST [Speech Therapy], OT [Occupational Therapy]" and "No further skilled care needed." The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 4. Review of P4's undated "Discharge Summary," located in a paper medical file, revealed the document was addressed to P4's PCP. The information documented on the form included: "Discipline Being Discontinued: SN [Skilled Nursing], " and "Goals met/maximum potential reached." The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 5. Review of P5's undated "Discharge Summary," located in a paper medical file, revealed the document was addressed to P5's PCP. The information documented on the form included: "Discipline Being Discontinued: PT, ST " and "Goals met." The form did not include information regarding discharge date, discharge condition, frequency of services, patient outcomes, post-discharge instructions, or current medications. 6. Review of P6's undated "Discharge Summary," located in a paper medical file, revealed the document was addressed to P6's PCP. The information documented on the form included: "Discipline Being Discontinued: PT, OT " and "Pt. [patient] achieved max functional [sic] and improved tolerance for functional task participation." The form did not include information regarding discharge date, discharge condition, frequency of services, post-discharge instructions, or current medications. During an interview on 08/19/25 at 11:30 AM, the Clinical Manager (CM) stated he/she completes the form when the patient is discharged from the agency and sends it to the PCP. The CM stated he/she was not aware of the extent of information identified in the agency policy that should be included in the summary.

One (1) Medical Facilities Inspector (MFI) from the Office of Licensure and Certification (OLC), Virginia Department of Health (VDH) conducted an unannounced Home Health Medicare Recertification Survey on November 8 - 10, 2021. As part of the inspection process, the agency's Emergency Preparedness Plan was reviewed. The agency was found to be in compliance with 42 CFR 484.113, the Condition of Participation - Emergency Preparedness for Home Health Agencies.

One (1) Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health, conducted an unannounced Medicare/Medicaid home health recertification survey at the above-noted agency from November 8, 2021 to November 10, 2021. The agency reported 12 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of seven (7) patients, four (4) personnel files, an agency admission packet, the complaint log, and zero (0) home visits due to the last active patient was discharged 11/08/2021, and multiple staff interviews were conducted. The agency was found not to be in compliance with 42 CFR 484, the Medicare Conditions of Participation for Home Health Agencies. Standard level 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 review of clinical records, staff interview and the patient's caregiver interview, it was determined the agency failed to ensure the physician was notified of the patient's condition that indicated the desired outcomes were not being met or changes were needed in the plan of care. Specifically, the physician was not notified about a patient's pain in one (1) of seven (7) clinical records that were reviewed in the survey sample and who experienced pain (Clinical record # 4). The findings: Seven (7) discharged clinical records were reviewed onsite on 11/9/2021 as paper chart access with the following findings: 1. The clinical record for patient #4 was reviewed for the certification period of 6/18/2021 to 8/16/2021 and contained documentation of the patient's pain status as a two (2) or three (3) to knees bilateral based on the pain scale for the entire certification period except on 6/25/2021, whereas a SN (Skilled Nurse) documented the pain as a (10). The agency utilized the standard numerical scale for rating pain with zero (0) being no pain and (10) being worse pain. A review of the SN notes for 6/25/2021 failed to reveal documentation of SN contacted the physician related to the patient's uncontrolled pain. On 11/09/2021 at 11:00 AM the MFI (Medical Facilities Inspector) interviewed the Administrator and Clinical Manager regarding the patient's pain status of a (10) on 6/25/2021. The Clinical Manager verified the physician had not been notified of the patient's pain status for that day. On 11/9/2021 and 11/10/2021 the MFI and Clinical Manager called the SN who documented the pain score on 6/25/2021. The SN was called multiple times at the agency and messages left with no call back. The Clinical Manager stated, this nurse left a few months ago to take care of her family member who was sick and may possibly be in another country. On 11/10/2021 at 8:52 AM the MFI called the patient's caregiver to verify if the patient had a pain rated as a (10) during the certification period. The patient's daughter stated, yes sometimes her knees hurts worse than other times and right now it is a (5) and is currently seeing a pain clinic doctor for this. The above noted findings regarding the failure of agency's staff to notify the physician of the patient's condition were reviewed with the Administrator and Clinical Manager during the clinical record review, and again at the exit conference of 11/10/2021.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on review of clinical records, staff interview and the patient's caregiver interview, it was determined the agency failed to document a complete patient pain assessment and/or failed to evaluate and document a patient's response to pain interventions for one (1) of seven (7) clinical records of patients who experienced pain in the survey sample (Clinical record # 4). The findings: Seven (7) discharged clinical records were reviewed onsite on 11/9/2021 as paper chart access with the following findings: 1. The clinical record for patient #4 was reviewed for the certification period of 6/18/2021 to 8/16/2021 and contained documentation of the patient's pain status as a (10) on 6/25/2021 based on the standard numerical scale for rating pain with zero (0) being no pain and (10) being worse pain. A review of the SN notes for 6/25/2021 failed to specify the location, exacerbating or relieving factors or the patient's response to pain interventions if any. On 11/09/2021 at 11:00 AM the MFI (Medical Facilities Inspector) interviewed the Administrator and Clinical Manager regarding the incomplete pain status specifics of 6/25/2021. The Clinical Manager verified the SN's incomplete pain documentation for 6/25/2021. On 11/9/2021 and 11/10/2021 the MFI and Clinical Manager called the SN who documented the pain score on 6/25/2021. The SN was called multiple times at the agency and messages left with no call back. The Clinical Manager stated, this nurse left a few months ago to take care of her family member who was sick and may possibly be in another country. On 11/10/2021 at 8:52 AM the MFI called the patient's caregiver to verify if the patient had a pain rated as a (10) during the certification period. The patient's daughter stated, yes sometimes her knees hurts worse than other times and right now it is a (5) and is currently seeing a pain clinic doctor for this. Caregiver also reported they were satisfied with the agency's pain management. The above noted findings regarding the failure of agency's staff to document the patient's pain assessment completely and evaluate the patient's pain in regards to their response to interventions if any were reviewed with the Administrator, and Clinical Manager during the clinical record review, and again at the exit conference of 11/10/2021.

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 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 within 5 business days of the patient's discharge for seven (7) of seven (7) discharged patients in the survey sample (Clinical records: #1-7). The findings: Seven (7) discharged clinical records were reviewed onsite on 11/9/2021 as paper chart access with the following findings: 1. The clinical record for patient #1 was reviewed for the certification period of 10/01/2021 to 11/29/2021. The record revealed that the patient was discharged from the agency on 11/8/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 2. The clinical record for patient #2 was reviewed for the certification period of 7/23/2021 to 9/20/2021. The record revealed that the patient was discharged from the agency on 8/26/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 3. The clinical record for patient #3 was reviewed for the certification period of 5/03/2021 to 7/01/2021. The record revealed that the patient was discharged from the agency on 6/23/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 4. The clinical record for patient #4 was reviewed for the certification period of 6/18/2021 to 8/16/2021. The record revealed that the patient was discharged from the agency on 8/05/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 5. The clinical record for patient #5 was reviewed for the certification period of 8/25/2021 to 10/23/2021. The record revealed that the patient was discharged from the agency on 10/16/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 6. The clinical record for patient #6 was reviewed for the certification period of 5/06/2021 to 7/04/2021. The record revealed that the patient was discharged from the agency on 6/21/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 7. The clinical record for patient #7 was reviewed for the certification period of 5/16/2021 to 7/14/2021. The record revealed that the patient was discharged from the agency on 7/14/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. On 11/19/2021 at 1:00 PM the MFI (Medical Facilities Inspector) asked the Administrator for the discharge summary to the physician. The Administrator stated, we send the discharge OASIS (Outcome and Assessment Information Set) but we do no keep the fax confirmations. The lack of providing a discharge summary within 5 business days of the patient's discharge was acknowledged prior to and reviewed during the exit conference with the Administrator on 11/10/2021 at 11 AM.