Every finding on record at Heaven's Touch Nursing Services LLC

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on January 25-26, 2021 by one (1) Medical Facilities Inspector from the Virginia Department of Health, Office of Licensure and Certification. 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 (Revised 02/21/2020).

An unannounced Medicare Medicaid Home Health Recertification survey was conducted January 25-26, 2021 at the above noted agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The survey was conducted onsite and remotely due to the COVID-19 pandemic. The agency was found not to be in compliance with the federal requirements of 42 CFR 484, Conditions of Participation for Home Health Agencies.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician. This ELEMENT is not met as evidenced by: Based on staff interview and document review it was determined the agency failed to ensure all services and treatments were administered only as ordered by a physician in one (1) of seven (7) clinical records reviewed in the survey sample (clinical record #7). The Findings were: Seven (7) clinical records were reviewed in the agency from 01/25/2021 through 01/26/2021. The clinical record for patient #7 was reviewed for the recertification period of 12/16/2020 through 02/13/2021. The plan of care contained wound care orders to the left outer foot to include cleanse with normal saline, Santyl to wound bed, cover with Mepilex border pad or 4x4 gauze and kling. The left heel was to be cleansed with normal saline, Santyl to wound bed, cover with gauze, abd pad, and kling wrap. A review of the nursing notes for 12/23/2020, 12/30/2020, 01/06/2021, 01/13/2021 and 01/20/2021 revealed the nurse was using Xeroform gauze in place of Mepilex for the left outer foot wound. An interview with the administrator on 01/26/2021 at 12:30 PM revealed the administrator had contacted the nurse about the Xeroform and the nurse stated the family had been using it and the nurse called the physician to ask if it was all right but failed to write an order.