Every finding on record at Housecall Medical Resources LLC

An unannounced Home Health Medicare Complaint Survey ID 71536 was conducted at the Martinsville branch location on 08/22/2022 by two (2) Medical Facilities Inspectors from the Office of Licensure and Certification, Virginia Department of Health. Parent Office 5221 Valley Park Drive, Suite 1a Roanoke, Va 24019 Branch Offices 305 N Washington Avenue Suite 305 Pulaski, Va 24301 2050 Langhorne Road, Suite 101 Lynchburg, Va 24501 1077 Spruce Street Martinsville, Va 24112 In conjunction with the survey the agency's complaint log, an admission packet, select policies and procedures and documents were reviewed. Focused clinical record review and multiple staff interviews were also conducted. The agency was not found to be in compliance with the Federal requirements of 42 CFR 484, the Medicare Conditions of Participation of Home Health Agencies. The complaint was substantiated with related deficiency cited.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, admission packet review, policy and procedure review and staff interview it was determine the agency failed to coordinate care with all physician’s involved in the patient’s plan of care. Specifically, the agency failed to ensure initial home health orders were approved by the patient’s primary care physician/non-physician practitioner for one (1) of one (1) focused clinical records reviewed in the survey sample (Clinical record #1) Findings: Clinical Record Clinical record #1 with a start of care date of 07/07/2022 was reviewed in the agency on 08/22/2022 for the certification period 07/07/2022 to 09/04/2022. The plan of care for the certification period contained orders for Skilled Nurse (SN) visits one (1) time a week for one (1) week, two (2) times a week for two (2) weeks then one (1) time a week for six (6) weeks. One (1) PRN (As Needed) visit for infusion complications. The plan of care contained orders for SN to obtain a blood sample for, a Complete Blood Count with Differential (CBC with Diff), Comprehensive Metabolic Panel (CMP) and Vancomycin Trough weekly. Review of the clinical record revealed results for the above noted labs obtained on 07/12/2022. The ordering physician/non-physician practitioner (Provider #1) was not the same as the physician/non-physician provider (Provider #2) reported on plan of care. Admission Packet The agency’s admission packet was reviewed in the agency on 08/22/2022 and contained a document titled Patient Eligibility Requirements select portion reads as follows “The patient must have an attending physician or allowed practitioner (as applicable by state law) who is willing and able to assume full responsibility for the patient’s medical care while receiving home health services. Policy & Procedure Agency’s policy and procedure titled Intake Referral/Admission Process was reviewed in the agency on 08/22/2022, select portions read as follows.. Upon the patient’s acceptance for admission to home care the physician/allowed practitioner will be notified. Findings of the initial assessment will be reported, additional orders will be obtained and the plan of care developed. Once a patient is admitted the admitting clinician will call the physician to provide report and receive any additional orders when indicated. Interview During an interview conducted in the agency on August 22,2022 with the Director of Professional Services (DOPS), Clinical Manager and Office Manager the Director Professional Services stated the referral for home health services came from a hospitalist and Provider #1 was listed as the patient’s primary care provider and was entered into their agency’s electronic medical record (EMR) and when the labs were collected on 07/12/2022 Provider #1 was sent the results. Provider #1 called the agency to advise she hadn’t seen this patient since 2021 and did not order labs, would not be signing home health orders and to remove her name. Agency immediately contacted Provider #2 who had seen patient while in the hospital and Provider #2 agreed to sign the plan of care and at that time the provider information was updated in the EMR. The DOPS stated the agency failed to contact the patient’s Primary Care Provider (PCP)/Provider #1 for approval of home services and plan of care on referral or Start of Care. The Business Director (BD) usually gets approval upon referral and enters a transition note in the patient medical record which was not done on this patient and during the start of care visit the patient was sent back to hospital but was sent back home and the admitting clinician didn't call either. The above noted findings were acknowledged by the Director of Professional Services during the clinical records reviews and again during the exit conference conducted in the agency on 08/22/2022.

Three (3) Medical Facilities Inspectors (MFI) from the Office of Licensure and Certification (OLC), Virginia Department of Health (VDH) conducted an unannounced Medicare Home Health Agency (HHA) recertification survey at the above-noted agency from April 5, 2021 to April 7, 2021. Due to the Covid-19 pandemic, survey activities were completed both onsite at the agency and offsite via secure email, secure remote access to electronic health records, and telephone. In conjunction with the survey, the MFIs reviewed the agency's Emergency Preparedness Plan (EPP). The agency was found not to be in compliance with 42 CFR 484.102, the Conditions of Participation for Emergency Preparedness for HHAs.

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 the agency developed individualized emergency preparedness plans as part of the comprehensive assessment for seventeen of seventeen clinical records reviewed in the survey sample (clinical records #1-17). The findings were: Two (2) Medical Facilities Inspectors (MFI) reviewed 17 clinical records as an offsite virtual review on April 5-6, 2021 using secure, read-only access to the agency's electronic health record (EHR) system. A review of the admission packet on entrance to the agency revealed the agency had a form titled "Patient Emergency Plan Identification Card" to fill out at the time of admission that would cover the individualized emergency preparedness plan (EPP). The form is a part duplicate form with one copy for the clinical record, one copy for the on-call book and one copy for the home folder per the instructions at the bottom of the form. At the top of the form, there is a place where the patient would be assigned a code based on certain criteria. During the course of clinical record reviews, no individualized emergency preparedness plans could be located in the electronic records. A phone interview was conducted with the Director of Operations (DOO), Staff Member #1, at 10:45 am on April 6, 2021 related to the findings. The DOO was provided by secure email, a list of names of the first ten (10) patients for record review to see if they could be locate the form. At 11:59 am the DOO responded back by email that the forms were unable to be located. The remaining records were reviewed with no evidence the emergency preparedness plan had been completed. Home visits were conducted with only one home having evidence the plan was completed: the plan for Patient #9. On April 7, 2021 at approximately 9:00 AM, Staff Member #11, the Area Vice President (AVP), was asked to see if the one home visit patient's form could be located in Patient #9's clinical record. Staff Member #11 was unable to locate the EPP plan. A review of the EPP policies and a document related to the patient emergency plan identification card provided by Staff Member #11 on April 7, 2021 revealed the following findings. The EPP policy titled "Agency Specific Emergency Management Plan Communication" states in part: Patient Classification System-The agency's goal is to maximize valuable resources and staff during a crisis situation. This means providing essential functions during a manmade or natural event. Individual plans for each patient must be included as part of the comprehensive patient assessment. This includes patient classification. The patient emergency plan identification card document contained the codes to assign patients with examples of why you might select a particular code. Codes are A-D and 1-3. For example, an A code would be assigned to a patient with special needs who could not have care interrupted and a 1 would be assigned if the patient required transportation to a medical facility or special needs evacuation shelter. An interview with Staff Member #11 at 9:25 AM revealed the emergency plan is based on the form filled out and the employee showed this surveyor where the "code" assigned was located in the computer however, the employee was unable to show there was an actual plan or that the form was filled out. The Director of Operations (DOO), Staff Member #1, acknowledged the above-noted deficiency during interviews on 04/06-07/2021. The DOO and Area Vice President, Staff Member #11, again acknowledged the above-noted deficiency during the exit conference on 04/07/2021 at approximately 11:00 AM.

Three (3) Medical Facilities Inspectors (MFI) from the Office of Licensure and Certification (OLC), Virginia Department of Health (VDH) conducted an unanounced Medicare Home Health Agency (HHA) recertification survey at the above-noted agency from April 5, 2021 to April 7, 2021. Due to the Covid-19 pandemic, survey activities were conducted both onsite and offsite via secure email, secure remote access to electronic health records, and telephone. The agency operates 2 branches which are located at: 1077 Spruce Street Martinsville VA 24112, and 2050 Langhorne Rad - Suite 103 Lynchburg, VA 24501. The agency was found not to be in compliance with 42 CFR 484, the Conditions of Participation for Home Health Agencies.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, it was determined the agency failed to provide a Home Health Change of Care Notice (HHCCN) to Medicare patients in advance of reducing/discontinuing services for two (2) of two (2) patients whose clinical records were reviewed in the survey sample for which an HHCCN was applicable (Clinical records #11 and 14). The findings were: Seventeen clinical records were reviewed by two (2) Medical Facilities Inspectors (MFI) as an offsite virtual review on April 5-6, 2021 with secure, read-only access to the agency's electronic health record (EHR) system. 1. The clinical record for Patient #11 contained plan of care orders for home health aide visits once a week for one (1) week then twice a week for five (5) weeks. A physician's order was written on 3/9/2021 to decrease home health aide visits to once a week. On 4/7/2021 at 10:15 AM the MFI asked staff member #11 (Area Vice President) if the patient was notified of the home health aide decrease in visits by means of a Home Health Change of Care Notice (HHCCN). Staff member #11 confirmed a HHCCN was not done. The clinical record failed to contain evidence the agency provided the patient an advanced notice (HHCCN) prior to decreasing the frequency of home health aide visits. 2. The clinical record for Patient #14 was reviewed for the certification period of 11/07/2020 through 01/05/2021. The plan of care contained orders for Occupational Therapy (OT) to visit two (2) times per week for four (4) weeks. The OT discontinued services early on week three (3) and wrote an order to visit only one (1) time on week three (3). The record failed to contain evidence a HHCCN had been obtained to discontinue OT early. On 4/7/2021 at 9 AM, the Medical Facilities Inspector asked staff member #11 if a HHCCN could be located in the record. Staff member #11 confirmed no HHCCN was on file. The Area Vice President acknowledged the above-noted deficiency during interviews on 04/07/2021. The Area Vice President and Director of Operations, Staff Member #1, again acknowledged the above-noted deficiency during the exit conference on 04/07/2021 at approximately 11:00 AM.

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 clinical record review, observations made by the Medical Facilities Inspector during home visits, staff interviews, and policy and procedure review, it was determined the agency failed to include all the required elements on each patient's individualized plan of care. Specifically, the agency failed to include oxygen orders and instructions on the plans of care for two (2) of four (4) patients receiving oxygen therapy who were reviewed as part of the survey sample: Patients #6 and #17. The agency also failed to provide patient-specific, individualized information on the plan of care regarding the location of a Peripherally Inserted Central Catheter for one (1) of one (1) patient who was receiving intravenous therapy and whose record was reviewed as part of the survey sample: Patient #7. The findings: Two (2) Medical Facilities Inspectors (MFI) conducted seven (7) home visits on 04/05-06/2021. Two (2) Medical Facilities Inspectors (MFI) reviewed the clinical records of 17 patients as an offsite virtual review utilizing secure, read-only access to the agency's electronic health record (EHR) system on 04/05-06/2021. 1. The MFI conducted a home visit to conduct observation of a Physical Therapy Assistant (PTA), Staff Member # 4, at the home of Patient #6 on 04/05/2021 at 1:45 PM. During the home visit, the MFI observed the patient receiving oxygen therapy via nasal cannula from an oxygen concentrator. The MFI asked the PTA if the patient was wearing oxygen. The PTA confirmed that the patient was wearing oxygen. The MFI asked the PTA at what rate the oxygen was being administered, per the PTA, the oxygen was being delivered at 4 liters per minute (L/min). Upon observation by the MFI, the patient's oxygen concentrator was set to 4.5 L/min. Patient #6's clinical record was reviewed for the period of 03/23/2021 to 05/21/2021. Patient #6's plan of care (POC) failed to list oxygen in the section labeled Medications, failed to provide any instruction for oxygen administration, and failed to include the device used to deliver the oxygen. 2. The clinical record for Patient #7 was reviewed for the certification period of 2/17/2021 to 4/17/2021. The plan of care contained a diagnosis of acute myeloblastic leukemia. The plan of care contained orders for a Skilled Nurse (SN) to perform/instruct patient/caregiver to flush IV [intravenous] access with normal saline and heparin utilizing SASH technique [SASH technique is a standard protocol used to describe the method by which IV access and tubing are maintained by preventing clots and clogs by administering normal saline and heparin into the tubing]. SN to perform site care for infusion access device PICC (peripherally inserted central catheter-a tube placed in the vein for medication administration) line dressing with dressing change to include transparent dressing. SN to cleanse access site with chloraprep and alcohol pad and cover with transparent dressing frequency weekly. On 4/5/2021 at 4:30 PM the MFI made a home visit to the patient and observed the PICC line to the left antecubital. The plan of care failed to contain the PICC line site/location. 3. The clinical record for patient #17 was reviewed for the certification period of 9/03/2020 through 11/01/2020. A review of the skilled nursing note on 9/18/2020 revealed the patient was using oxygen 2 liters via nasal cannula at night. The plan of care failed to contain oxygen. The MFI requested the agency's policy and procedure regarding care plan development on 04/07/2021 at approximately 9:00 AM from the Director of Operations (DOO), Staff Member #1. The DOO provided a policy and procedure titled "Physician Orders and Medical Supervision of the Plan of Care," Policy number TX-001. The agency's policy included the following information: "The current 485 [an informal name for the plan of care form used by the agency] will include...Supervision of Medications and Treatments...Patient specific interventions and education...other items that may be patient or diagnosis specific." The policy goes on to state that in regard to orders for oxygen the physician order must include the "type of oxygen therapy, administration device and liter flow rate or concentration." The above-noted deficiency was acknowledged by the Area Vice President, Staff Member #11, and the DOO on 04/07/2021 during the exit conference at approximately 11:00 AM.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on staff observation during a home visit, staff interview, and policy and procedure review, it was determined the agency failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases. Specifically, during a home visit, the Medical Facilities Inspector observed a skilled nurse's failure to follow infection prevention standards related to hand hygiene, bag technique, and the provision of wound care for one (1) of one (1) patients receiving wound care during a home visit conducted in conjunction with the survey: Patient #8. The findings: Two (2) Medical Facilities Inspectors (MFI) conducted seven (7) home visits in conjunction with the survey on 04/05-06/2021. Two (2) MFIs reviewed the clinical records of 17 patients as an offsite virtual review using secure, read-only access to the agency's electronic health record (EHR) system on 04/05-06/2021. 1. The MFI conducted a home visit to the home of Patient #8 on 04/06/2021 at 9:05 AM to observe the Skilled Nurse (SN), Staff Member #7. According to Patient #8's plan of care (POC), signed 02/15/2021, the SN was to provide the following wound care: "Skilled nurse to perform/teach patient/caregiver pressure ulcer care to Stage 2 pressure ulcer [an injury to the skin resulting from pressure, typically over a bony prominence] to left buttocks. Irrigate/cleanse with wound cleanser or saline or soap and water, pat dry with gauze, apply maxorb cover with foam dressing. Change dressing 2x [two times] weekly. Caregiver may change in absence of SN visit for soiled or dislodged dressing." The MFI observed the SN perform wound care during the home visit. After cleansing the wound, the SN then grabbed the clean dressing supplies with soiled gloves. After applying the new dressing to the wound site, the SN then removed one glove with the soiled dressing contents contained within it and disposed of the glove. The SN then replaced the disposed glove with a new glove and entered their bag to obtain vital sign collection materials. The SN failed to perform hand hygiene and change gloves after removing a soiled dressing and prior to touching clean wound care supplies and failed to perform hand hygiene after having direct patient contact before re-entering the clean bag to retrieve clean supplies. The MFI interviewed the SN at the home visit. The MFI asked the SN if hand hygiene was performed after providing wound care and before re-entering the clean supply bag. The SN confirmed that hand hygiene failed to be performed. 2. The MFI requested the agency's hand hygiene, bag technique, and wound care provision policies and procedures from the Director of Operations (DOO) on 04/06/2021 at approximately 3:30 PM. The DOO provided a policy and procedure titled "Hand Hygiene," policy number PCP-001. In part, it read "Perform hand hygiene as follows...after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings...after removing gloves." The policy and procedure titled "Bag Technique," policy number PCP-002, in part, read as follows: "Staff should not re-enter the bag with used gloves. Always perform hand hygiene before entering bag...The field staff member cleanses hands prior to accessing materials from the supply bag. Refer to hand hygiene policy as indicated." Finally, the policy and procedure titled "The Provision of Wound and Skin Care," policy number WC-001, read as follows: "Procedure...Hold soiled dressing in hand and remove glove to wrap inside out around dressing. Repeat with second glove and discard in disposable bag. Perform hand hygiene per policy. Don non-sterile gloves" prior to applying clean dressing. The SN failed to perform hand hygiene between removing the soiled dressing and applying the new dressing, after completing wound care, and prior to re-entering the bag to retrieve clean supplies as directed in the above-noted policies and procedures for hand hygiene, bag technique, and the provision of wound care. The MFI discussed the above-noted deficient practice with the DOO on 04/06/2021 at approximately 4:45 PM. The DOO and Area Vice President, Staff Member #11, again acknowledged the above-noted deficiency during the exit conference on 04/07/2021 at 11:00 AM.