Every finding on record at Interim Healthcare

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on May 31-June 2, 2022 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 the Conditions of Participation: Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on May 31, -June 2, 2022 by one (1) Medical Facilities Inspector from the Virginia Department of Health Office of Licensure and Certification. The agency reported 89 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of seven (7) patients, five (5) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, vaccination rule and three (3) home visits were reviewed. Multiple staff interviews were also conducted. The agency was found not to be in compliance with 42 CFR 484, the Medicare Conditions of Participation for Home Health Agencies. Standard level deficiencies were identified and cited in this report.

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. 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 patients were informed about and consented to the frequency of proposed visits in advance of starting care for two (2) of seven (7) patients in the survey sample (Clinical records #'s: 3 and 4). The findings: Seven electronic clinical records were reviewed in read only mode from June 1-2, 2022. 1. The informed consent signed at the time of admission and prior to services being provided for patient #3 with a start of care date of 11/15/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 2. The informed consent signed at the time of admission and prior to services being provided for patient #4 with a start of care date of 1/14/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. The lack of documentation at the time of admission and prior to services being provided regarding the frequency of services to be provided was reviewed with the Regional Operations Manager prior to and during the exit conference on 6/02/2022

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 a review of clinical records and staff interview, it was determined the agency failed to ensure it completed a review of all medications the patient is currently using in order to identify any potential adverse effects and or drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy in three (3) of seven (7) patients whose clinical records were reviewed in the survey sample. (Clinical record #'s: 1, 3, and 4). The findings: Seven electronic clinical records were reviewed in read only mode from June 1-2, 2022. 1. The clinical record for patient #1 was reviewed for the certification period of 4/05/2022 to 6/03/2022. The agency's Skilled nurse documented on 4/17/2022, 5/03/2022 and 5/12/2022 that the patient took Norco (an opioid pain reliever) for pain relief that was not listed on the patient's medication profile. In addition the Skilled nurse documented on 4/21/2022 that the patient took "Oxy" (opioid pain reliever) for pain relief that was also not listed on the patient's medication profile. The Regional Operations Manager acknowledged that Norco or Oxy were not listed on the patient's medication profile. 2. The clinical record for patient #3 was reviewed for the certification period of 11/15/2021 to 1/13/2022. The agency's Skilled nurse documented on 11/17/2022, 11/19/2022, 11/22/2022 and 11/24/2022 that the patient took Tylenol for pain relief that was not listed on the patient's medication profile. The Regional Operations Manager acknowledged that Tylenol was not listed on the patient's medication profile. 3. The clinical record for patient #4 was reviewed for the certification period of 1/14/2022 to 3/14/2022. The agency's Skilled nurse documented on the start of care (1/14/2022) that the patient was on continuous oxygen at 2.5 liters per minute that was not listed on the patient's medication profile. The Regional Operations Manager acknowledged that oxygen was not listed on the patient's medication profile. The above noted findings regarding the failure of agency's staff to update the patient's medication profile were reviewed with Regional Operations Manager during the clinical record review, and again with the Regional Operations Manager and the Director of Nursing at the exit conference of 6/02/2022.

Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This STANDARD is not met as evidenced by: Based on a review of clinical records and staff interview, it was determined the agency failed to send a patient's transfer OASIS (Outcome and Assessment Information Set) to the receiving hospital and/or to another home health agency for a safe and effective transition of care for one (1) of two (2) closed clinical records reviewed in the survey sample. (Clinical record # 4). The findings: Two (2) closed, electronic clinical records were reviewed in read only mode from June 1-2, 2022. 1. The clinical record for patient #4 was reviewed for the certification period of 1/14/2022 to 3/14/2022. The record revealed that the patient was transferred from the agency on 2/18/2022 to a hospital then to another home health agency. No transfer OASIS was sent to the receiving hospital or home health agency. On 6/1/2022 at 4:24 PM the Regional Office Manager acknowledged the lack of a transfer OASIS. The lack of providing a transfer OASIS was acknowledged prior to and during the exit conference with the Regional Operations Manager and the Director of Nursing on 6/2/2022.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records and interviews it was determined the agency staff failed to follow the individualized plans of care. Specifically, there were missed visits that the physician was not notified about for two (2) of seven (7) patients in the survey sample (Clinical records #'s:,1 and 7). The findings: Seven electronic clinical records were reviewed in read only mode from June 1-2, 2022. 1. The clinical record for patient #1 was reviewed for the certification period of 4/5/2022 to 6/03/2022. Skilled nursing was ordered to provide services one (1) time per week for one (1) week, then two (2) times per week for eight (8) weeks. The clinical record contained documentation of less than 2 visits per week as noted below: - one (1) SN visit was documented for the week of 5/21/2022 through 5/27/2022 (week 8 for SN). On 6/2/2022 at 9 AM, the Regional Operations Manager acknowledged the missed visit did not contain a missed visit note or a notification to the physician of the missed visit and stated, that nurse had COVID during that time and that may had been the reason. 2. The clinical record for patient #7 was reviewed for the recertification period of 5/3/2022 to 7/01/2022. Physical Therapy was ordered to provide services two (2) times per week for nine (9) weeks. The clinical record contained documentation of less than 2 visits per week as noted below: - one (1) PT visit was documented for the week of 5/03/2022 through 5/06/2022 (week 1 for PT). - one (1) PT visit was documented for the week of 5/07/2022 through 5/13/2022 (week 2 for PT). - one (1) PT visit was documented for the week of 5/14/2022 through 5/20/2022 (week 3 for PT). - one (1) PT visit was documented for the week of 5/21/2022 through 5/27/2022 (week 4 for PT). On 6/2/2022 at 10 AM, the Director of Nursing acknowledged the missed visit did not contain a missed visit note or a notification to the physician of the missed visit and stated, I remember seeing a note from the therapist that the patient requested one visit per week but I can't find it. The lack of documentation regarding services being provided according to the above noted plans of care was reviewed and acknowledged by the Regional Operations Manager and the Director of Nursing on 6/02/2022.

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 the plan of cares included evidence the patient participated in goal setting and/or agreed with goals identified by the Home Health Agency; a description of the patient's risk for emergency department visits and hospital re-admissions. In addition, a plan of care failed to contain the specific location of a wound with wound care ordered by the physician for four (4) of seven (7) patients in the survey sample (Clinical record #'s: 1, 2, 3, and 4). The findings: Seven electronic clinical records were reviewed read only mode from June 1-2, 2022. 1. The clinical record for patient #1 was reviewed for the certification period of 4/05/2022 to 06/03/2022. The plan of care failed to contain documented evidence of the risk for rehospitalization or emergency department visits. On 6/2/2022 at 9 AM the Regional Operations Manager acknowledged the incomplete documentation related to the risk for rehospitalization or emergency department visits for above note plan of care and stated, the clinician didn't finish completing it. 2. The clinical record for patient #2 was reviewed for the recertification period of 4/06/2022 to 6/04/2022. The plan of care contained orders for skilled nursing as follows: skilled nursing to cleanse wound with soap and water (or no rinse foam), pat dry, apply calcium alginate to wound, dress with Unna boot and secure with Coban. The location of the wound was not specified in the plan of care orders. On 6/02/2022 at 10:30 AM the Director of Nursing acknowledged the lack of identification/location of the wound on the plan of care. A review of the record revealed the wound was located on the right lower extremity. 3. The clinical record for patient #3 was reviewed for the certification period of11/15/2022 to 1/13/2022. The plan of care failed to contain evidence the patient/caregiver participated in goal setting. 4. The clinical record for patient #4 was reviewed for the certification period of 1/14/2022 to 3/14/2022. The plan of care failed to contain evidence of the documented risk for rehospitalization or emergency department visits. The above noted findings regarding the lack of the required content of the plan of care was reviewed with the Regional Operations Manager and the Director of Nursing during the exit conference on 6/02/2022.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff interviews, it was determined the agency failed to send the patient's transfer summary within 2 business days of becoming aware of an unplanned transfer in one (1) of two (2) closed clinical records reviewed in the survey sample. (Clinical record # 4). The findings: Two (2) closed, electronic clinical records were reviewed in read only mode from June 1-2, 2022. 1. The clinical record for patient #4 was reviewed for the certification period of 1/14/2022 to 3/14/2022. The record revealed that the patient was transferred from the agency on 2/18/2022. The record failed to contain documented evidence of a transfer summary sent to the primary physician. On 6/1/2022 at 4:24 PM the Regional Operations Manager acknowledged there was no documented evidence that a transfer summary was sent to the primary physician. The lack of providing a transfer within 2 business days was acknowledged prior to and during the exit conference with the Regional Operations Manager and the Director of Nursing on 6/2/2022.