Every finding on record at Dominion Care Management Group LLC

A Recertification Survey entrance conference was conducted on 07/26/22 at 10:02 a.m. with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing. Census: L&C (Licensed and Certified Home Health): 99 LHH (Licensed Home Health): 38 An exit conference was conducted on 07/29/22 at 2:55 p.m. with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing. The preliminary findings were discussed. The agency was in substantial compliance with 42 CFR Part 484.22, Emergency Preparedness Requirements for Home Health Agencies.

A Recertification Survey entrance conference was conducted on 07/26/22 at 10:02 a.m. with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing. Census: L&C (Licensed and Certified Home Health): 99 LHH (Licensed Home Health): 38 An exit conference was conducted on 07/29/22 at 2:55 p.m. with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing. The preliminary findings were discussed, and written instructions were provided for submitting a plan of correction within ten days of the receipt of the Statement of Deficiencies. POC –Plan of Care SN -Skilled Nurse DON-Director of Nursing

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 clinical record review and interview, the agency failed to ensure that Plans of Care included safety measures to protect against injury and activity orders and supplies for one of twelve patients (Patient #10) whose records were reviewed. Patient #10's plan of care failed to list Oxygen under Medications. This failure could place the agency's patients at risk of receiving inadequate care and services and could place the patients at risk of declining health and hospitalizations. The findings included: Review of Client #10's clinical record revealed a document titled, "Home Health Certification and Plan of Care (POC)" for a certification period of 04/26/22 - 06/24/22, signed and dated by Physician on 05/20/22. The POC revealed a Principal Diagnosis of Hypertensive Heart Disease with Heart Failure, with other diagnoses of Chronic Diastolic (Congestive) Heart Failure, Chronic right heart failure, Biventricular heart failure, pressure ulcer of left Buttock, unstageable. The POC also included orders for skilled nurse to instruct patient/caregiver on signs/symptoms of exacerbation to report, instruct weight to be obtained daily and weight gain of two pounds overnight or five pounds in one week be reported to physician. If unable to weigh patient, skilled nurse to obtain measurement of calves at each visit and report increase in measurement to physician. The POC failed to list Oxygen under Medications. During an interview and record review on 07/29/22 at 2:35 p.m., the findings above were reviewed and discussed with the Administrator/Director of Nursing and the Alternate Administrator/Alternate Director of Nursing during which they both confirmed the findings. Review of the agency's Administrative Policy Manual revealed a policy titled, "Plan of Care", dated July 15, 2020. The document read in part the following, “...The Plan of Care shall be completed in full to include l. Medications, treatments, and procedures…”