Every finding on record at Chesapeake Hospital Authority Chesapeake General Hospital

An unannounced Home Health Agency recertification survey was conducted on August 9-11, 2021 by two (2) Medical Facilities Inspectors 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 out of compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview it was determined the agency failed to ensure the agency developed individualized emergency preparedness plans as part of the comprehensive assessment for six (6) of seventeen (17) clinical records reviewed in the survey sample (clinical record #2, 3, 4, 7, 8, and 9). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 9-11, 2021. Clinical records #2, 3, 4, 7, 8 and 9 all failed to contain an individualized emergency preparedness plan (EPP) as part of the comprehensive assessment. Staff member #1 was advised of the findings on 8/10/2021 and was to check to see if the documents could be located. An interview conducted with staff member #1 at 9 am on August 11, 2021 revealed the EPP were not located for the above noted clinical records. The findings were reviewed with administrative staff prior to and during the exit conference.

An unannounced Home Health Agency recertification survey was conducted on August 9-11, 2021 by two (2) Medical Facilities Inspectors from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 1543 unduplicated admissions for the past twelve months. In conjunction with the survey, seventeen (17) clinical records, seven (7) personnel files, an admission packet, complaint log, emergency preparedness, CLIA (Clinical Laboratory Improvement Amendments) and the organization chart were reviewed. Seven (7) home visits and staff interviews were conducted. The agency was found not to be in compliance with the federal requirements of 42 CFR 484, Conditions of Participation for Home Health Agencies. Deficiencies were identified and cited in this report.

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 interviews and document review, it was determined the agency failed to ensure that patients were informed about and consented to the frequency of proposed visits in advance of starting care in two (2) of seventeen (17) clinical records reviewed in the survey sample (clinical record #'s 3 and 14). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 9-11, 2021. The clinical records reviewed during the survey contained a form titled "consent for treatment" which contained a section titled frequency of visits. Under that section is a list of each discipline and a line beside them for the clinician to fill in the visit frequency. On clinical records #3 and #14, the admitting clinician failed to document the visit frequency for those disciplines who would be providing services. An interview was conducted on August 10, 2021 beginning at 11 am with staff member #1 regarding the missing information. Staff member #1 stated, I can't find it either, it looks like it just wasn't documented.. The findings were reviewed with administrative staff prior to and during the exit conference on August 1, 2021 beginning at 11 am.

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 review of clinical records and interview 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 for one (1) of (17) clinical records reviewed in the survey sample (Clinical record #3). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 9-11, 2021. Clinical record #3 failed to contain evidence the patient was notified in advance of providing care of the extent to which payment may be expected from federally-funded payors or the amount the patient may have to pay. Staff member #1 was interviewed and advised of the above findings and attempted to locate the missing information/document but was unable to provide the information prior to the survey exit.

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 interview and a review of clinical records it was determined the agency's staff failed to ensure each plan of care contained specific information required on the plan of care for five (5) of seventeen (17) clinical records reviewed in the survey sample . Specifically, the plan of care failed to contain specific orders for wound care and Foley catheter care. In addition, pain was not added to a care plan when it was needed to address a patient's symptoms. clinical records #2, 4, 6, 10, and 14 The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 9-11, 2021. 1. Clinical record #2 was reviewed for the certification period of 1/17/2021 through 3/17/2021. The plan of care contained orders for wound care however, failed to specify the location of the wound. 2. Clinical record #4 was reviewed for the certification period of 3/01/2021 through 4/29/2021. The plan of care contained orders for a Foley catheter however, the plan failed to state the size of the Foley catheter and the frequency to change the catheter. 3. Clinical record #6 was reviewed for the certification period of 7/14/2021 through 9/11/2021. A verbal order was written to update the plan of care with orders for wound care on 7/28/2021. The orders do not specify where the wound was located. The patient also had a wound vac (vacuum) that was discontinued and the staff failed to write an order to discontinue the wound vac. 4. Clinical record #10 was reviewed for the certification period of 6/11/2021 through 8/09/2021. The plan of care had interventions listed as: perform wound care/dressing change: wound vac (vacuum) change every M-W-F (Monday, Wednesday, Friday) set wd (wound) vac for 150. The plan of care failed to identify where the wound was located. 5. Clinical record #14 was reviewed for the certification period of 7/16/2021 through 9/13/2021. The plan of care failed to contain interventions and goals for pain on a patient identified on admission and throughout care as having significant pain. The above findings were discussed with staff member #1 August 9 - 10, 2021 during the end of day conference. Staff member #1 stated, she was unable to find the specifics within the plan of care but was able to locate them elsewhere in the charts The findings were reviewed with the administrative staff prior to and during the exit conference.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on staff interview and review of clinical records it was determined the agency staff failed to follow physicians orders and failed to notify the physician of missed visits for four (4) of seventeen (17) clinical records in the survey samples (clinical records #5, 7, 9, and 10). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 9-11, 2021. 1. Clinical record #5 was reviewed for the certification period of 1/17/2021 through 3/17/2021. The plan of care contained physician orders for skilled nursing services 2 wk (week) 1 wk (two times a week times one week), 1 wk 6 wk, 3 prn (as needed) ending 4/03/2021. In addition, the order for Physical therapy (PT) services was for, 1 wk 1 ending 2/20/2021, 2 wk 3 wk ending 3/13/2021 and 2 wk 3 wk ending 3/13/2021. The skilled nurse documented missed visits on 3/5/2021 and 3/6/2021. The PT documented missed visits on 2/26/2021, 3/2/2021 and 3/5/2021. The clinical record failed to contain evidence the physician was notified of the missed visits. 2. Clinical record #7 was reviewed for the certification period of 7/13/2021 through 9/10/2021. The plan of care contained physician orders for Occupation therapy (OT) services 2 m (month) 1 m (two times a month times one month), 2 wk 1 wk ending 8/7/2021. The OT documented a missed visit on 7/30/2021. The clinical record failed to contain evidence the physician was notified of the missed visit. 3. Clinical record #9 was reviewed for the certification period of 6/13/2021 through 8/11/2021. The plan of care contained physician orders for skilled nursing services 1 wk 1 (one time a week times one week), 2 wk 3 wk, 1 wk 3 wk, and 3 prn ending 7/31/2021. The skilled nurse documented missed visits on 6/18/2021, 6/22/2021 and 7/27/2021. The clinical record failed to contain evidence the physician was notified of the missed visits. 4. Clinical record #10 was reviewed for the certification period of 6/11/2021 through 8/9/2021. The plan of care contained physician orders for skilled nursing services 3 wk 8 wk ending 8/7/2021. The skilled nurse documented missed visits on 6/25/2021 and 7/7/2021. The clinical record failed to contain evidence the physician was notified of the missed visits. An interview with staff member #1 on the first day of the survey revealed missed visit notes are faxed to the physician. The staff member (#1) was asked to provide evidence throughout the survey process of the missed visit notes being faxed. As of the exit on 8/11/2021, no evidence was presented of the above missed visits having been sent to the physician prior to the start of the survey. The above findings were reviewed with the administrative staff prior to and during the exit conference.

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 and interviews, it was determined the agency failed to ensure the physician was notified of the patient's condition that indicated 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 for one (1) of seven (7) clinical records reviewed in the survey sample of patients who experienced pain (Clinical record #14). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 9-11, 2021. The clinical record for patient #14 revealed the patient had pain which was rated consistently around seven (7) out of ten (10) during the three (3) weeks of care and was currently receiving care by the physical therapist (PT). The PT notes stated the patient's goal for pain was 0-3. During the PT visit on 7/19/2021, right after admission, the patient reported being out of pain medication. The PT advised the patient to call the physician to get refills. During the initial evaluation, the PT had requested skilled nursing, social work and home health aide services to see the patent. The record failed to indicate services had been started. During the home visit on 8/10/2021, the PTA was interviewed. The PTA advised the patient had not been able to participate in some therapy due to pain and the plan was to discharge the patient, as they did not think she could reach any further goals currently. The patient is to see the physician on 8/11/2021 and would like to continue with outpatient therapy. The patient advised she was able to obtain more pain medication. At approximately 2:30 PM on August 10, 2021, staff member #1 was interviewed and asked about the nursing, social work and aide not starting services. Staff member #1 was also asked to check on why the PT had the patient call the physician rather than the PT call. On 8/11/2021, an interview with staff member #1 revealed the physician managing the patients care had not signed the orders (written 7/20/2021) and was not always prompt in signing orders so care had not been started by the other disciplines. The physician's office did fax the signed order for additional disciplines on August 11, 2021. The skilled nurse is to go see the patient on 8/11/2021 (same day) to assess the patient and assist with pain management. Staff member #1 reports having a conversation with the PT and the PT advised they did call the physician about the pain/pain medications but failed to document it in the clinical record. The findings were reviewed with administrative staff prior to and during the exit conference.

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 clinical record review and staff interview, it was determined the agency failed to send the patient's discharge summary to the primary care physician within five (5) business days of discharge for three (3) of five (5) discharged patients in the survey sample (Clinical records #1, 2, and 4). The findings were: A review of the five discharged electronic clinical records was conducted on August 9-10, 2021. 1. Clinical record #1 was reviewed for the certification period of 2/07/2021 through 4/07/2021. The patient was discharged from the agency on 3/4/2021. The discharge summary was not sent to the physician until 4/14/2021. 2. Clinical record #2 was reviewed for the certification period of 1/17/2021 through 3/17/2021. The patient was discharge from the agency on 3/17/2021 and there was no evidence the discharge summary was sent to the physician. 3. Clinical record #4 was reviewed for the certification period of 3/1/2021 through 4/29/2021. The patient was discharge from the agency on 3/3/2021 and the discharge summary was not sent to the physician until 4/19/2021. Staff member #1 was interviewed on August 9 and 10, 2021 regarding the discharge summaries. Staff member #1 provided the fax confirmation(s) for the clinical records #1 and 4 on August 10, 2021. The findings were reviewed with administrative staff prior to and during the exit conference.