Every finding on record at Home & Heart Health, Inc

An unannounced Medicare Medicaid Home Health Agency recertification survey was conducted July 5-7, 2022 and July 11-12, 2022 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 1159 unduplicated admissions in the last twelve (12) months with an active census of 162 patients. The following were completed/reviewed in conjunction with the survey: Seven (7) home visits, seventeen (17) clinical records, eight (8) personnel files, review of selected policies and procedures, the agency's complaint log, emergency preparedness plan, and Covid vaccination records. Interviews were also conducted. In conjunction with this survey, the agency's emergency preparedness plan was reviewed. Deficiencies were identified and cited in this report. The agency was found to be out of compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview it was determined the agency failed to ensure that the agency developed individualized emergency preparedness plans as part of the comprehensive assessment for seventeen (17) of seventeen (17) patients whose clinical records were reviewed in the survey sample (clinical records #1-17). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from July 5-7, 2022 and July 11, 2022. Clinical records #1-17 failed to contain an individualized emergency preparedness plan (EPP) as part of the patient's comprehensive assessment. Staff member #1, the clinical manager was interviewed on 7/7/2022 at 9:20 am and stated the agency does have three categories patients are placed in based on needs which are acute, sub-acute and stable. The definitions with examples of each are provided in the agency's emergency plan. The acute category is for patients needing visits that day. Sub-acute is for patients that may wait for 24-48 hours for a visit and stable is for visits that may be postponed for up to 4 days. The agency calls the patient to assess needs on a routine basis during emergencies and the patients are assigned a one of the categories based on needs at the time. Those needs fluctuate during care. The agency has no individualized plan or form that is filled out at the time of admission as part of the comprehensive assessment. The patient does sign a form at admission with a section titled home safety evaluation/emergency plan that states in part: I understand that if I am scheduled for a visit during an emergency, man-made of natural (including, but not limited to, snow/ice storms, floods or industrial accidents); I will be contacted by a representative of Home and Heart Health Inc. who will make arrangement for my care. The findings were reviewed with administrative staff prior to and during the exit conference.

An unannounced Medicare Medicaid Home Health Agency recertification survey was conducted July 5-7, 2022 and July 11-12, 2022 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 1159 unduplicated admissions in the last twelve (12) months with an active census of 162 patients. The following were completed/reviewed in conjunction with the survey: Seven (7) home visits, seventeen (17) clinical records, eight (8) personnel files, review of selected policies and procedures, the agency's complaint log, emergency preparedness plan, and Covid vaccination records. Interviews were also conducted. No deficiencies were identified. The agency was found to be in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs).