Every finding on record at Home Nursing Services of Southwest VA, Inc

An unannounced Home Health Agency recertification survey was conducted on June 28-30, 2021 by two (2) Medical Facilities Inspectors 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 Home Health Medicare/Medicaid recertification survey was conducted on June 28-30, 2021 by two (2) Medical Facilities Inspectors from the Virginia Department of Health, Office of Licensure and Certification. The agency reported 730 unduplicated admissions for the past twelve months. In conjunction with the survey, seventeen (17) clinical records, five (5) personnel files, an admission packet, complaint log, emergency preparedness, CLIA (Clinical Laboratory Improvement Amendments) and the organization chart were reviewed. Seven (7) home visits and staff interviews were conducted. The agency was found not to be in compliance with the federal requirements of 42 CFR 484, Conditions of Participation for Home Health Agencies. Deficiencies were identified and cited in this report.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview it was determined the agency' staff failed to ensure a plan of care contained specific information needed to provide care for two (2) of seventeen (17) records reviewed in the survey sample (record #1 and 3). Specifically, the location of a wound vac, the care of a facial wound and the actual site of a PICC line were left off the plan of care. The findings were: The electronic medical records were reviewed in read-only mode both onsite and offsite on 6/28-29/2021. 1. The clinical record for patient #1 revealed a plan of care that contained orders to change the PICC line (peripherally inserted central catheter) dressing every week. The plan of care failed to specify where the PICC line was located. A review of the clinical record also indicated the patient had a large wound on the right jaw with exposed bone. The patient was being seen by the cancer clinic and the patient's caregiver was managing the wound however, the nurse was assessing and teaching regarding the wound on weekly visits. The plan of care failed to contain any mention of the wound or interventions. 2. The clinical record for patient #3 revealed a plan of care with orders to remove a Prevena wound vac (dressing applied on a surgical wound that uses negative pressure - like a vacuum) in 5 days/when wound vac stops functioning. The plan of care failed to identify where the wound vac/surgical site was located. An interview was conducted with the Clinical Manager, staff #2 at 3:30 PM on 6/29/2021. Staff #2 reviewed the plan of care with the surveyor and acknowledged the above noted findings.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interview it was determined the agency failed to ensure that services were provided only as ordered by a physician for one (1) of seventeen (17) clinical records reviewed in the survey sample (record #9). The findings were: The electronic medical records were reviewed in read-only mode both onsite and offsite on 6/28-29/2021. A review of the clinical record for patient #9 revealed a plan of care with wound care orders to the left foot and left toe. The plan of care also states in part, "assess wound to left calf", but failed to contain physician orders for wound care. A review of the record revealed that agency staff are performing the same wound care as they are doing for the left foot to include cleaning with normal saline, pat dry, apply bacitracin and xeroform to the wound bed and cover with gauze, secure with kling and tape. An interview with the Clinical Manager, staff #2 on 6/29/2021 at 3:30 PM revealed staff #2 believes the foot wound and calf wound are connected. Staff #2 acknowledged the record does not indicate the wounds are connected and there is no anatomical drawing with the location of the wounds or other documentation to clarify the location.