Every finding on record at Emporia Home Care Services LLC

Two (1) Medical Facilities Inspectors (MFI) from the Office of Licensure and Certification (OLC), Virginia Department of Health (VDH) conducted an unannounced Home Health Medicare Recertification Survey on August 23-25, 2021. As part of the inspection process, the agency's Emergency Preparedness Plan was reviewed. The agency was found to be in compliance with 42 CFR 484.113, the Condition of Participation - Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency August 23-25, 2021 by two Medical Facilities Inspectors from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 835 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, (17) clinical records and five (5) personnel files were reviewed. Seven (7) 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. 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 clinical record reviews, 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 six (6) of (17) clinical records reviewed in the survey sample. (Clinical record #'s 1, 2, 3, 5, 14, and 16). The findings: Seventeen clinical records were reviewed offsite and onsite on 8/24/2021 and 8/25/2021 with read only access with the following findings. 1. The clinical record for patient #1 was reviewed for the certification period of 1/21/2021 to 3/21/2021. Patient #1's consent form, contained a preprinted field for the discipline's proposed frequency to be written in, however TBD (to be determined) was handwritten in that field. Patient #1's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. The patient was to receive nursing and physical therapy services. 2. The clinical record for patient #2 was reviewed for the certification period of 8/5/2020 to 10/3/2020. Patient #2's consent form, contained a preprinted field for the discipline's proposed frequency to be written in, however TBD (to be determined) was handwritten in that field. Patient #2's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. The patient was to receive nursing, occupational and physical therapy services. 3. The clinical record for patient #3 was reviewed for the certification period of 5/16/2020 to 7/14/2020. Patient #3's consent form, contained a preprinted field for the discipline's proposed frequency to be written in, however TBD (to be determined) was handwritten in that field. Patient #3's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. The patient was to receive nursing and physical therapy services. 4. The clinical record for patient #5 was reviewed for the certification period of 5/19/2021 to 7/17/2021. Patient #5's consent form, contained a preprinted field for the discipline's proposed frequency to be written in, however TBD (to be determined) was handwritten in that field. Patient #5's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. The patient was to receive nursing and physical therapy services. 5. The clinical record for patient #14 was reviewed for the certification period of 8/4/2021 to 10/2/2021. Patient #14's consent form, contained a preprinted field for the discipline's proposed frequency to be written in, however TBD (to be determined) was handwritten in that field. Patient #14's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. The patient was to receive nursing, occupational and physical therapy services. 6. The clinical record for patient #16 was reviewed for the recertification period of 8/7/2021 to 10/5/2021. Patient #16's consent form, contained a preprinted field for the discipline's proposed frequency to be written in, however TBD (to be determined) was handwritten in that field. Patient #16's clinical record failed to contain evidence that the patient was informed about and consented to the proposed frequencies for the home health disciplines that were to participate in their care. The patient was to receive nursing services. The above noted findings regarding the lack of providing patients a written notice in advance of the proposed frequencies of disciplines to furnish care was acknowledged by the Administrator during the exit conference conducted on 8/25/2021 at 12:00 PM.

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 a review of clinical records, staff interviews and the agency's transfer/discharge policy, it was determined the agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit. Additinally the agency failed to send the patient's transfer summary within 2 business days of becoming aware of an unplanned transfer for four (4) of five (5) closed clinical records reviewed in the survey sample. (Clinical record #'s 2, 3, 4 and 5). The findings: Five (5) closed clinical records were reviewed offsite and onsite on 8/24/2021 and 8/25/2021 with read only access with the following findings. 1. The clinical record for patient #2 was reviewed for the certification period of 8/5/2020 to 10/3/2020. The record revealed that the patient was transferred from the agency on 8/11/2020 and a transfer summary was sent to the primary physician on 8/18/2020; 7 days later. 2. The clinical record for patient #3 was reviewed for the certification period of 5/16/2020 to 7/14/2020. The record revealed that the patient was transferred from the agency on 6/24/2020 and a transfer summary was sent to the primary physician on 7/1/2020; 7 days later. 3. The clinical record for patient #4 was reviewed for the certification period of 5/14/2021 to 7/12/2021. The record revealed that the patient was transferred from the agency on 7/9/2021 and a transfer summary was sent to the primary physician on 8/25/2021; 47 days later. 4. The clinical record for patient #5 was reviewed for the certification period of 5/19/2021 to 7/17/2021. The record revealed that the patient was discharged from the agency on 6/15/2021 and a discharge summary was sent to the primary physician on 8/25/2021; 71 days later The MFI (Medical Facilities Inspector) requested the agency's policy regarding completing transfer and discharge summaries on 8/25/2021. The Administrator provided the MFI with a policy titled, "Patient Discharge/Transfer Process," policy number 2.1.004. A portion of the policy reads as follows, "A transfer summary is sent to the primary care physician and the facility to which the patient is transferred within 2 business days of planned transfer or becoming aware of unplanned transfer. A discharge summary is sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 business days of a patient's discharge. The agency failed to ensure that transfer summaries were transmitted to the primary physician within two (2) business days of becoming aware of unplanned transfer and a completed discharge summary was transmitted to the primary physician within five (5) business days of discharge from the agency. The lack of providing a discharge summary within 5 business days of the patient's discharge and a transfer within 2 business days was acknowledged prior to and during the exit conference with the Administrator on 5/25/2021 at 12:00 PM.