Every finding on record at Commonwealth Home Health Inc

An unannounced Home Health Agency recertification survey was conducted on May 3-7, 2021 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 Home Health Agency recertification was conducted May 3-7, 2021 by one MFI (Medical Facilities Inspector) from The Office of Licensure and Certification, Virginia Department of Health. The survey occurred both onsite and remotely due to the COVID-19 Public Health Emergency. The agency reported 947 unduplicated admissions in the last twelve (12) months. The agency was found not to be in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs) and deficiencies were cited.

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 review of clinical records and interview, it was determined the agency failed to ensure it completed 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 in all patients. One (1) of (17) clinical records reviewed in the survey sample failed to have a complete review of all medications. (Clinical record # 9). The findings: Seventeen (17) clinical records were reviewed 5/3-6/2021 with read only access of the electronic medical records. 1. The clinical record for Patient #9 was reviewed for the certification period of 4/9/2021 to 6/7/2021. The agency's Skilled nurse documented on 4/12/2021 that an LPN (Licensed Practical Nurse) within the ALF's (assisted living facility) memory care unit administered to the patient Ibuprofen for pain. Ibuprofen is not listed on the patient's medication profile. A phone interview was conducted with the primary caregiver on 5/6/2021 at 12:30 PM. The caregiver stated, I have put (patient #9) on hold with the agency because she is in so much pain when anyone moves her. The doctor had called in Ibuprofen to help with the pain. An interview was conducted with the Clinical supervisor on 5/6/2021 at 3:48 PM. The Clinical supervisor verified that Ibuprofen was not listed on the patient's medication profile. The above noted findings regarding the failure of agency's staff to update the patient's medication profile were reviewed with Clinical supervisor during the clinical record review, and again with the Alternate Administrator at the exit conference of 5/7/2021.

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 review of clinical records and staff interview it was determined the agency's staff failed to follow the plan of care as ordered by the physician for one (1) out of (17) clinical records reviewed in the survey sample (Clinical record # 17). The findings: Seventeen (17) clinical records were reviewed 5/3-6/2021 with read only access of the electronic medical records. 1. The clinical record for Patient #17 was reviewed for the certification period of 4/2/2021 to 5/31/2021. The plan of care contained physician orders as follows: Skilled nurse to assess blood sugar monitoring and results. Notify MD as indicated. The clinical record revealed there was no Skilled nurse documentation for blood sugar assessments/monitoring for this time frame. An interview was conducted with the Clinical supervisor on 5/6/2021 at 11:30 AM. The Clinical supervisor stated, the nurse noted this on the 5/5/2021 Skilled nursing visit note that the patient's wife was non-compliant with taking blood sugars and only takes if needed. The clinical record failed to contain documentation that the patient's physician was notified of the patient's blood sugar not being assessed/monitored during the above noted time frame. The above noted findings regarding the failure of agency's staff conformance with physician's orders were reviewed with Clinical supervisor during the clinical record review, and again with the Alternate Administrator at the exit conference of 5/7/2021.

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 observations, patient/caregiver interviews, review of the agency's pain policy, and review of clinical records, 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. Specifically, 11 of 12 clinical records reviewed of patients who experienced pain in the survey sample failed to have a complete pain assessment documented, (Clinical record #s: 1, 2, 5, 6, 7, 8, 9 10, 12, 13 and 14). The findings: Seventeen (17) clinical records were reviewed 5/3-6/2021 with read only access of the electronic medical records. Clinical records revealed, the agency utilized a standard numerical scale for rating pain with zero (0) being no pain and (10) being worse pain. This scale was not used for Patient #9 who was nonverbal. In addition, the clinical notes indicated that all the following patients were in acceptance of their current pain management regimen. An interview was conducted with each patient to verify the documented pain regime acceptance. The findings are as follows: On 5/4/2021 at 5:41 PM the MFI reviewed the agency's pain policy and procedure titled "Pain Management". Portions of the policy read as follows: A thorough pain assessment of the client will occur at the time of admission and on a regular basis throughout the care episode and will be documented completely on the discipline visit note. Reports of such findings will be made to the supervisor for possible intervention as indicated and documentation will be completed to demonstrate the care coordination activity. A thorough pain assessment will include, evaluation of adherence and response to interventions. Evaluate the effectiveness of treatment or medication currently used to control the patient's pain. 1. The clinical record for Patient #1 was reviewed for the recertification period of 8/25/2020 to 10/23/2020. A review of the Skilled nursing notes revealed the patient's lowest pain level was documented as a seven (7) for all visits with the exception of pain reaching as high as (10) for one other visit. The patient's medication profile contained the narcotic pain medications of Oxycodone and OxyContin. Many of the clinical notes from skilled nursing contained documentation of relief measures for pain by means of "narcotic analgesics", however, the notes did not indicate how often, which narcotic or how much the patient was taking of Oxycodone or OxyContin for pain relief. Throughout the clinical visit notes from the skilled nurse, there was no follow up pain evaluation in response to the pain intervention rendered. A phone interview by this inspector was conducted with the primary caregiver on 5/4/2021 at 1:30 PM. The caregiver stated, she was satisfied with the agency's pain management for (patient #1), and further stated, I fill the narcotics in the pill box for (patient #1) every day because OxyContin is given three (3) times a day and then Oxycodone as needed five (5) times a day as needed for break through pain and I hide the pill bottles. The caregiver further explained that (patient #1) does not receive anything over the as needed prescribed amount of Oxycodone because (patient #1) has a habit of taking too much pain medications in the past and has a pain management physician (name withheld). The clinical record did not contain the above caregiver's information regarding the limited amount of narcotics being dispensed, that the patient had a pain management physician or any follow up pain evaluations in response to pain interventions being rendered. 2. The clinical record for Patient #2 was reviewed for the recertification period of 9/28/2020 to 11/26/2020. A review of the Skilled nursing clinical notes revealed the patient's pain level was a one (1) on one visit and pain reaching as high as a six (6) on several other visits. A review of the Occupational therapy clinical notes revealed the patient's lowest pain was an eight (8) on several visits with pain reaching as high as a nine (9) on the remaining visits. In addition, the Occupational therapy visit dated 11/3/2020 indicated that the patient had increased pain but it was not rated. Throughout the clinical visit notes from all disciplines, there were no follow up pain evaluations documented in response to the pain interventions rendered. A phone interview was conducted by this inspector with the patient on 5/6/2021 at 8:49 AM. The patient stated, I was satisfied with their pain management care, they did everything they could but I had this same pain for (20) years and I am currently seeing a pain specialist (name of facility withheld); I still don't have relief. The clinical record did not contain a complete pain assessment, the patient's history of chronic unrelieved pain issues or any follow up pain evaluations in response to pain interventions. 3. The clinical record for Patient #5 was reviewed for the recertification period of 10/21/2020 to 12/19/2020. A review of the Skilled nursing clinical notes revealed the patient's pain was rated as a five (5) for the first recertification visit and the skilled nurse did not document a pain assessment for the last visit on 10/28/2021 before discharge. Throughout the clinical record, there was no follow up pain evaluation in response to the pain intervention(s) rendered. A phone interview was conducted by this inspector with the primary caregiver on 5/6/2021 at 9:10 AM. The caregiver stated, I was satisfied with the agency's pain management for (patient #5). 4. The clinical record for Patient #6 was reviewed for the certification period of 4/7/2021 to 6/5/2021. A review of the Skilled nursing clinical notes revealed the patient's pain was rated as a zero (0) for one visit and then pain reaching as high as a four (4) for another visit. The Skilled nurse visit on 4/13/2021 and 4/29/2021 indicated the patient had pain but it was not rated. The patient's medication profile contained a muscle relaxant and antispastic medication Baclofen, an antidepressant medication Amitriptyline for back pain, a nerve medication Gabapentin, an anticonvulsant and nerve medication of Topamax. Many of the clinical notes from skilled nursing did not contain documentation of pain relief measures except for the visit on 4/13/2021 when a "narcotic analgesics", which indicated Amitriptyline was a relief measure for the back pain. A review of the Physical therapy clinical note dated 4/8/2021 revealed the patient had pain but it was not rated and no pain assessment was documented for 4/12/2021, 4/21/2021 and 4/26/2021. In addition, a review of the Occupational therapy clinical note dated 4/13/2021 revealed a pain score of a three (3) and the pain was described as muscle spasms with no documented location of where the muscle spasms were. Throughout the clinical visit notes from all disciplines, there were no documented follow up pain evaluations in response to the interventions rendered. A phone interview was conducted by this inspector with the patient on 5/6/2021 at 9:50 AM. The patient stated, I am satisfied with the agency's pain management but my primary care physician abruptly stopped the Baclofen on 4/23/2021 which was for both my knees hyper flexion; the agency has set me up an appointment for me to see a pain specialist so I can get my Baclofen again. The clinical record did not contain complete pain assessments or any follow up pain evaluations in response to pain interventions. 5. The clinical record for Patient #7 was reviewed for the certification period of 4/12/2021 to 6/10/2021. A review of the Physical therapy clinical notes revealed the patient's pain rating was a two (2) for one visit and a pain rating reaching as high as a six (6) for three other visits. The Physical therapy clinical note dated 4/26/2021 did not document a pain assessment. Throughout the clinical visit notes by Physical therapy, there was no follow up pain evaluation in response to pain intervention(s) rendered. A phone interview by this inspector was conducted with the primary caregiver on 5/6/2021 at 10:15 AM. The caregiver stated, I am satisfied with the agency's pain management, my brother used to get steroid and gel shots in his right knee that never helped but since the agency has been here he has been getting up without my help, so the agency is helping. The clinical record did not contain a complete pain assessment or follow up pain evaluation in response to pain interventions rendered. 6. The clinical record for Patient #8 was reviewed for the certification period of 4/9/2021 to 6/7/2021. A review of the clinical notes by nursing revealed the patient's pain score was a zero (0) for one visit and pain reaching as high as a seven (7) for one other visit. Throughout the clinical visit notes from Skilled nursing, there was no documented follow up pain evaluation in response to the pain intervention(s) rendered. A phone interview by this inspector was conducted with the primary caregiver on 5/6/2021 at 10:15 AM. The caregiver stated, I am satisfied with the agency's pain management because they are doing a good job with her arthritis and fibromyalgia and there is no indication to change or add to her medication...her Tramadol helps. 7. The clinical record for Patient #9 was reviewed for the certification period of 4/9/2021 to 6/7/2021. A review of the Skilled nursing clinical notes revealed the patient's pain was a zero (0) for two visits and pain reaching as high as a 10 for one other visit using the FLACC behavioral pain assessment (used for non-verbal patients or patients who are unable to self-report pain. An observation of the face, legs, activity, cry and consolability are scored with zero (0) being no pain and (10) being worse pain). The patient's medication profile contained a non-narcotic pain medication of Acetaminophen. Many of the clinical notes from skilled nursing contained documentation of relief measures for the pain by means of "non-narcotic analgesics". The Skilled nursing clinical notes did not indicate how often and/or which non-narcotic pain medication was used for pain. A phone interview by this inspector was conducted with the primary caregiver on 5/6/2021 at 12:30 PM. The caregiver stated, I have put (patient #9) on hold with the agency because she is in so much pain when anyone moves her. The doctor has called in Ibuprofen to help with the pain. We don't want to give her too much pain medicine because then she won't eat or sleeps too much. The Physical therapy clinical notes for this time frame indicated the patient had pain but did not score the patient's pain and documented, "unable to assess pain". The Physical therapy clinical note of 4/22/2021 did not document a pain assessment. Throughout the clinical visit notes from all disciplines, there was no follow up pain evaluation in response to the pain intervention rendered. The clinical record did not contain the above caregiver's information regarding limited non-narcotic use, a complete pain assessment or follow up pain evaluation(s) in response to any intervention(s). 8. The clinical record for Patient #10 was reviewed for the certification period of 4/5/2021 to 6/3/2021. A review of the skilled nursing clinical notes revealed the patient's pain was scored as a three (3) for one visit and pain reaching as high as an (8) for four other visits. The patient's medication profile contained non-narcotic and narcotic pain medications of Acetaminophen and Oxycodone. Many of the clinical notes from Skilled nursing contained documentation of relief measures for pain by means of "narcotic analgesics and over the counter pain relievers", however it did not indicate how often and/or how much non-narcotic or narcotic medication the patient was taking for pain. A review of the Physical therapy clinical notes revealed the patient's pain was a four (4) during one visit and pain reaching as high as an eight (8) on one visit. In addition, the remaining Physical therapy visits indicated the patient had pain but it was not rated on 4/13/2021, 4/30/2021 and 5/5/2021. Throughout the clinical visit notes from all disciplines, there were no follow up pain evaluation(s) in response to the pain interventions rendered. A phone interview by this inspector was conducted with the primary caregiver on 5/6/2021 at 10:43 AM. The caregiver stated, the therapists and nurses are asking about his pain, he has arthritis and they motivate him to put his legs up when they hurt and show him how to properly move around to help with pain. The clinical record did not contain the above caregiver's information regarding the above mentioned interventions, a complete pain assessment or follow up pain evaluations in response to any intervention. 9. The clinical record for Patient #12 was reviewed for the certification period of 4/2/2021 to 5/31/2021. A review of the Physical therapy clinical notes revealed the patient's pain score was a three (3) at the start of care visit however, the remaining Physical therapy visits indicated the patient had pain but it was not rated for the dates of 4/6/2021, 4/9/2021, 4/13/2021, 4/22/2021, 4/29/2021, 5/3/2021 and there was no documented pain assessment for 4/16/2021 or 4/20/2021. Throughout the clinical visit notes from Physical therapy, there was no follow up pain evaluation in response to the pain interventions rendered. A home visit was conducted on 5/3/2021 at 2:00 PM. The patient stated, her back pain was much better since the therapist requested the ALF to lower the bed by removing the box springs. The patient complained of left leg pain and the therapist recommended leg massage to which the patient agreed. The clinical record did not contain a complete pain assessment or a follow up pain evaluation in response to the pain intervention. 10. The clinical record for Patient #13 was reviewed for the certification period of 4/9/2021 to 6/7/2021. A review of the skilled nursing clinical notes revealed the patient's pain was a four (4) for one visit and the pain reaching as high as an (8) for one other visit. A review of the Physical therapy clinical notes revealed the patient's pain as a five (5) on one visit with pain reaching as high as a (10) out of two visits. Throughout the clinical visit notes from all disciplines, there was no follow up pain evaluation in response to the intervention rendered. A phone interview was conducted by this inspector with the primary caregiver on 5/6/2021 at 11:52 AM. The caregiver stated, the agency has been above and beyond with their help. The nurses for the agency have come out here and given her enemas and called the doctor multiple times, so they have been very helpful. The clinical record did not contain follow up pain evaluation(s) in response to pain interventions. 11. The clinical record for Patient #14 was reviewed for the certification period of 4/9/2021 to 6/7/2021. A review of the Physical therapy clinical notes revealed the patient's pain score was a five (5) for all visits. Throughout the clinical visit notes from all disciplines, there were no follow up pain evaluations in response to the intervention rendered. A home visit was conducted by this inspector with the patient on 5/4/2021 at 8:45 AM. The caregiver stated, I have back and shoulder pain but I manage the medication myself because I prefer to take Acetaminophen for that and not so much Oxycodone. The clinical record did not contain any follow up pain evaluation in response to any intervention. 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 was reviewed with the Administrator, Alternate Administrator and Clinical Supervisor during the clinical record review, and again with the Alternate Administrator at the exit conference of 5/7/2021.