Every finding on record at Goodheart Healthcare Services, Inc

Two (2) Medical Facilities Inspectors (MFI) from the Virginia Department of Health (VDH) Office of Licensure and Certification (OLC) conducted a Medicare Recertification survey at the above-noted agency from September 11, 2023 - September 12, 2023. In conjunction with the recertification survey, the MFIs reviewed the agency's Emergency Preparedness Plan (EPP). The agency was found in compliance with 42 CFR 484.102, the Conditions of Participation, Emergency Preparedness for Home Health Agencies. No deficiencies were identified.

Two (2) Medical Facilities Inspectors (MFI) from the Virginia Department of Health (VDH) Office of Licensure and Certification conducted an unannounced Medicare Recertification survey at the above-noted agency from September 11, 2023 to September 12, 2023. The agency was found not to be in compliance with 42 CFR 484, the Conditions of Participation for Home Health Agencies. The agency reported an unduplicated census for the last 12 months of 262 patients. In conjunction with the survey, the MFIs conducted the following: review of seven (7) Clinical records: five (5) active patient records and two (2) closed/discharged records; three (3) home visits; review of three (3) personnel files; review of the agency's complaint log; review of a patient admission packet; review of the agency's Emergency Preparedness Plan (EPP); multiple interviews with agency staff; and review of selected policies and procedures. Standard level deficiencies were identified and cited.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities in four (4) of seven (7) medical records reviewed in the survey sample. Medical Record #'s 2, 4, 5, and 6. Findings: Seven (7) medical records were reviewed in the agency on 09/12/23 with the agency's Administrator (staff member #1) and Intake Coordinator (staff member #2) assisting in review of the electronic record. The medical record for patient #2 with a start of care date of 08/08/23 was reviewed for the certification period 08/08/23-10/06/23. The medical record failed to contain documentation that the patient or representative's signature was obtained to confirm receipt of the notice of patient rights and responsibilities. The medical record for patient #4 with a start of care date of 08/22/23 was reviewed for the certification period 08/22/23-10/20/23. The medical record failed to contain documentation that the patient or representative's signature was obtained to confirm receipt of the notice of patient rights and responsibilities. The medical record for patient #5 with a start of care date of 08/04/23 was reviewed for the certification period 08/04/23-10/02/23. The medical record failed to contain documentation that the patient or representative's signature was obtained to confirm receipt of the notice of patient rights and responsibilities. The medical record for patient #6 with a start of care date of 08/04/23 was reviewed for the certification period 08/04/23-10/02/23. The medical record failed to contain documentation that the patient or representative's signature was obtained to confirm receipt of the notice of patient rights and responsibilities. The lack of documented signatures related to receipt of patient rights and responsibilities was discussed with staff members' #1 and #2 at 2:00 PM on 09/12/23. Staff member #2 stated that most of the agency's patients reside in assisted living facilities and are unable to sign their own documents due to cognitive impairments. In these cases, admission information to include the proposed disciplines to provide care, the frequencies of their visits, the patient's financial liability for payment (if any), and patient rights and responsibilities are verbally communicated to the responsible party via phone call and admission documents are emailed to them. The responsible party is expected to sign the consent document and return to the agency. Staff member #2 stated he/she keeps a list of all that are not returned and continually follows up, but acknowledged it was sometimes difficult to obtain the signature. Staff member #1 and #2 confirmed the agency currently has no policy for obtaining a verbal consent for treatment and/or policy for obtaining the signature confirming receipt of patient rights information in advance of furnishing care to the patient. The above noted deficiency was again acknowledged by staff member #'s 1 and 2 during the exit conference on 09/12/23.

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 staff interview and document review, it was determined the facility failed to keep an accurate and complete list 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 of seven (7) medical records reviewed in the survey sample. Medical record #'s 2, 3, and 5. Findings: Seven (7) medical records were reviewed 09/12/23 with the agency's Administrator and Intake coordinator assisting in the review of the electronic record. The medical record for patient #2 with a start of care date of 08/08/23 was reviewed for the certification period of 08/08/23 - 10/06/23. The clinical documentation indicated the patient had a sacral ulcer that the agency was treating with medihoney, xerofoam, and a foam dressing. The agency failed to document medihoney on the patient's medication list. The medical record for patient #3 with a start of care date of 06/08/23 was reviewed for the certification periods of 06/08/23 - 08/06/23 and 08/07/23 - 10/05/23. Agency staff was using medihoney to treat an ulcer on the patient's right heel beginning 06/08/23. The patient's medication profile was not updated for either certification period to include medihoney. The medical record for patient #5 with a start of care date of 08/04/23 was reviewed for the certification period of 08/04/23 - 10/02/23. The medical record contained documentation that the patient had multiple wounds. The agency was using Santyl topically to treat the patient's right heel wound. The patient's medication profile failed to include Santyl. Medication profiles were discussed with staff member #1 and #2 on 09/12/23 at 2:15 PM. The staff members acknowledged that the topical wound care medications were not on the patient's profiles and that the medication profiles should include all medications the patient was using.