Every finding on record at Cuidado Casero Home Care of Virginia, Inc.

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted on August 1-3, 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 Home Health Agency Medicare Medicaid recertification survey was conducted on August 1-3, 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 77 unduplicated admissions in the last twelve (12) months with an active census of 21 patients. The following were completed/reviewed in conjunction with the survey: Three (3) home visits, seven (7) clinical records, five (5) personnel files, review of selected policies and procedures, complaint log, emergency preparedness plan, Covid vaccination records and interviews were 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).

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 clinical record 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 four (4) of seven (7) clinical records reviewed in the survey sample (clinical record #2, 4, 5, and 7). The findings were: A review of the admission packet on 8/01/2022 revealed a form titled “Assignment of Benefits/Consent”. The form contained a section titled Medicare with three separate boxes that could be checked to include one which states in part: I understand that Medicare part A pays 100%, another states, I further understand that Medicare part B usually pays 80% of all approved services and a third box which states I further understand that it is my right to receive an Advance Beneficiary Notice for services that the agency does not believe Medicare will cover in advance to services provided or of reducing or terminating ongoing care. The next section of the form is titled Medicaid or Insurance and also has three boxes with one stating I understand that in Virginia, Medicaid pays 100% of services. The second box states I understand that services, supplies and equipment must be authorized by my insurance company and I am responsible to meet any deductible, copayment or coinsurance required by my insurance plan. The last box is a blank space for the name of the insurance to be written and states, is hereby authorized and directed to pay any and all benefits due me directly to (name of home care agency). The last section of the form is titled Private Pay and has one box which states my estimated charges as a private pay patient is as follows (per visit rate) and has a place to document the rate. The electronic clinical records were reviewed from 8/01/2022 through 8/03/2022 in read only mode. 1. Clinical record #2 with a start of care date of 3/08/2022 was reviewed for the certification period of 3/08/2022 through 5/06/2022. The “Assignment of Benefits/Consent” form failed to be completed indicating what the payor source was and any amount the patient would be responsible to pay. 2. Clinical record #4 with a start of care date of 6/06/2022 was reviewed for the certification period of 6/06/2022 through 8/04/2022. The “Assignment of Benefits/Consent” form failed to be completed indicating what the payor source was and any amount the patient would be responsible to pay. 3. Clinical record #5 with a start of care date of 7/06/2022 was reviewed for the certification period of 7/06/2022 through 9/03/2022. The “Assignment of Benefits/Consent” form failed to be completed indicating what the payor source was and any amount the patient would be responsible to pay. 4. Clinical record #7 with a start of care date of 8/08/2018 was reviewed for the certification period of 7/18/2022 through 9/15/2022. The “Assignment of Benefits/Consent” form failed to be completed indicating what the payor source was and any amount the patient would be responsible to pay. An interview was conducted with the administrator, staff #1 at 9 am on 8/03/2022 to review the findings and request copies of the consents for all patients in the survey sample. The copies were provided at approximately 11:45 AM. During a review of the copies it was noted that the consents that were left incomplete in the electronic record had been filled out. The administrator was asked if the consent forms had been completed after printing. The administrator denied the forms were filled out after printing. The consents were reviewed again in the electronic record and it was revealed that the “Assignment of Benefits/Consent” form for patient #2, 4, 5, and 7 were still left blank in the electronic record. A second interview was conducted with the administrator, staff #1 at 12:54 PM. The administrator acknowledged the records had been altered after printing copies for the surveyor and stated “I didn’t do it but I directed it to be done”.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to provide a Home Health Change of Care Notice (HHCCN) to Medicare patients in advance of reducing/discontinuing services for one (1) of one (1) clinical record in the survey sample for which a HHCCN was applicable (clinical record #2) The findings were: The electronic clinical records were reviewed onsite and offsite from 8/01/2022 through 8/03/2022 in read only mode. Clinical record # 2 was reviewed for the certification period of 3/08/2022 through 5/06/2022. The plan of care was for skilled nursing and physical therapy services for nine (9) weeks. The patient only received skilled nursing services for four (4) weeks and physical therapy for (8) weeks and then the patient was discharged. The clinical record failed to contain evidence of a Home Health Change of Care Notice (HHCCN). An interview conducted with the administrator, staff #1 on 8/03/2022 at 1:05 PM revealed the patient refused further care and was discharged, however the administrator acknowledged that was not documented in the clinical record.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined that the agency failed to update or revise the comprehensive assessment within 48 hours of a patient's return to the home from a hospital admission of 24 hours or more for one (1) of two (2) patients who had a resumption of care following a hospital admission and whose clinical records were reviewed in the survey sample (clinical record #3) The findings were: The electronic clinical records were reviewed from 8/01/2022 through 8/03/2022 in read only mode. Clinical record #3 was reviewed for the certification period of 7/02/2022 through 8/30/2022. Skilled nursing notes and a hospital discharge note revealed the patient was hospitalized from 7/15/2022 through 7/25/2022. A resumption of care/update to the comprehensive assessment was not completed on the patient until 7/29/2022. An interview with the administrator, staff #1 at 1:20 PM on 8/03/2022 revealed the resumption of care was completed late on the patient.

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 a review of clinical records and interviews it was determined agency staff failed to ensure plans of care contained measurable goals for five (5) of seven (7) patients whose records were reviewed in the survey sample (clinical records #1-5). The findings were: The electronic clinical records were reviewed from 8/01/2022 through 8/03/2022 in read only mode. 1. Clinical record #1 was reviewed for the certification period of 1/25/2022 through 3/26/2022. The plan of care failed to contain measurable goals. 2. Clinical record #2 was reviewed for the certification period of 3/08/2022 through 5/06/2022. The plan of care failed to contain measurable goals. 3. Clinical record #3 was reviewed for the certification period of 7/02/2022 through 8/30/2022. The plan of care failed to contain measurable goals. 4. Clinical record #4 was reviewed for the certification period of 6/06/2022 through 8/04/2022. The plan of care failed to contain measurable goals. 5. Clinical record #5 was reviewed for the certification period of 7/06/2022 through 9/30/2022. The plan of care failed to contain measurable goals. An interview was conducted with the administrator, staff #1 at 9 AM on 8/03/3022 to review the findings. The administrator stated not knowing why there were no goals as that is something the administrator does when reviewing the plan of care. The administrator was to look to see if it was a problem when printing out the plans of care. No resolution was presented to this surveyor prior to the exit conference on 8/03/2022.

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 an interview and a review of clinical records it was determined agency staff failed to follow physician orders on the plans of care for one (1) of seven (7) patients whose records were reviewed in the survey sample (clinical record #5). Specifically the physical therapist (PT) failed to make visits as ordered in the plan of care. The findings were: The electronic clinical records were reviewed from 8/01/2022 through 8/03/2022 in read only mode. Clinical record #5 was reviewed for the certification period of 7/06/2022 through 9/03/2022. The plan of care contained physician orders for the physical therapist (PT) to visit two times per week for seven (7) weeks. The PT did not make a visit during the first week of the certification period. The first visit was not conducted until 7/14/2022 which was the second week of the certification period. The clinical record failed to contain documentation related to the missed visit or evidence the physician was notified of the change to the plan of care. An interview was conducted with the administrator, staff #1 at 9 am on 8/03/2022 to review the findings. The administrator was to look at the record to see if a note could be located. No note was presented prior to the exit conference on 8/03/2022.

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 a completed transfer summary to a hospital where a patient was admitted for care within two (2) business days of becoming aware of the unplanned transfer for one (1) of two (2) patients with unplanned hospital admissions and whose clinical records were reviewed in the survey sample (clinical record #3). The findings were: The electronic clinical records were reviewed from 8/01/2022 through 8/03/2022 in read only mode. Clinical record # 3 was reviewed for the certification period of 7/02/2022 through 8/30/2022. Skilled nursing notes and a hospital discharge note revealed the patient was hospitalized from 7/15/2022 through 7/25/2022. The clinical record failed to contain a transfer summary. An interview with the administrator, staff #1 at 1:20 PM on 8/03/2022 revealed that a transfer summary had not been completed.