Every finding on record at Edmarc Hospice for Children

An unannounced Home Health Agency recertification survey was conducted on September 05-07, 2023 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 Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency September 05-07, 2023 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 75 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, seven (7) clinical records and four (4) personnel files were reviewed. Three (3) home visits and were conducted. The agency was found to be out of compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. A Deficiency was identified and cited in this report.

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 clinical record review, agency policy and staff interview, it was determined the agency failed to ensure accurate and complete medication reviews for three (3) of seven (7) clinical records reviewed in the survey sample (clinical records #2, 3, and 7). Findings: Seven electronic clinical records were reviewed in the agency with staff member #5 as the navigator on September 06, 2023. 1. The clinical record for patient #2 was reviewed for the period of 07/12/23 to 09/10/23. The clinical record contained a plan of care with a medication profile. A portion of the medication profile was incomplete as follows: TPN electrolytes intravenous (Total Parenteral Nutrition-a nutrition class of drugs used to treat malnourishment); SMOFlipid intravenous (class of drug known as fatty acids); Heparin lock flush intravenous (anticoagulant to keep intravenous catheters open and flowing); metronidazole oral (antibiotic). During the clinical record review, the surveyor asked staff member #5 why the medications were not complete. Staff member #5 stated, "I didn't realize TPN was considered a drug." Staff member #5 acknowledged the above medications did not contain dosages or frequencies. 2. The clinical record for patient #3 was reviewed for the period of 02/17/23 to 04/18/23. The clinical record contained a plan of care with a medication profile. A portion of the medication profile was incomplete as follows: Lasix oral; Plaquenil oral; Iron oral; Probiotic oral and Prednisone oral. During the clinical record review staff member #5 acknowledged the above medications did not contain dosages or frequencies. 3. The clinical record for patient #7 was reviewed for the period of 07/08/23 to 09/06/23. The clinical record contained a plan of care with a medication profile. A portion of the medication profile was incomplete as follows: Ursodiol oral; Omeprazole oral; Guanfacine oral; Fluconazole oral and Acyclovir oral. During the clinical record review staff member #5 acknowledged the above medications did not contain dosages or frequencies. The agency's policy and procedure for medication reviews titled "Administration of Medication, policy number C107, read in part as follows: "All medications shall be documented on the Plan of Care, and the medication profile. Both shall include route, dose and frequency of administration." The lack of documentation related to the above noted patient's medication profiles was reviewed with the Executive Director during the exit conference.