Every finding on record at Interim Healthcare of Collinsville

An unannounced Home Health Agency recertification survey was conducted on April 21 - 23, 2025, by one (1) Medical Facilities Inspector 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 Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency April 21-23, 2025 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency was found to be out of compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. 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, 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 four (4) of seven (7) patients in the survey sample (Clinical record Patient #'s: 2, 4, 6 and 7). The findings: The informed consent signed at the time of admission and prior to services being provided for Patient #2, with a start of care date of January 15, 2025 failed to contain documentation of the frequency of Physical Therapy services the patient would be receiving.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 March 14, 2025 failed to contain documentation of the frequency of Physical Therapy services the patient would be receiving.The informed consent signed at the time of admission and prior to services being provided for Patient #6, with a start of care date of April 14, 2025 failed to contain documentation of the frequency of Physical Therapy services the patient would be receiving.The informed consent signed at the time of admission and prior to services being provided for Patient #7, with a start of care date of March 12, 2025 failed to contain documentation of the frequency of Physical Therapy services the patient would be receiving.The informed consents failed to ensure patients were informed about and consented to the frequency of proposed Physical Therapy service visits. On April 23, 2025 at 12:30 PM, the Medical Facilities Inspector (MFI) conducted an interview with Staff Member #2. Staff Member #2 revealed using evaluate and treat for the Physical Therapy frequencies but will document the proposed frequency moving forward.

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 review of clinical records and interview it was determined the agency's staff failed to ensure home health services were provided according to the patient's individualized plan of care for one (1) of two (2) clinical records that required an SASH (method used to maintain patency of a PICC line) flush to a PICC (tube in the vein of arm used to deliver medications and blood draws) line reviewed in the survey sample (Clinical record for Patient #1). The findings: The clinical record for patient #1 was reviewed for the period of March 11, 2025 to March 31, 2025. The patient's plan of care contained orders as follows: PICC dressing weekly and as needed using sterile technique provided, allow to air dry, cover with transparent occlusive dressing. Flush with SASH (S=Saline flush; A=Administer fluids/medications; S=Saline flush and H=Heparin flush) method. The clinical record failed to contain documentation that the nurse flushed the PICC with Heparin with the SASH method. On April 23, 2025 at 12:40 PM, the Medical Facilities Inspector (MFI) conducted an interview with Staff Member #2. Staff Member #2 revealed the patient had developed bruising around the PICC line and the patient's son indicated not to use the Heparin flush anymore. Staff Member #2 was unable to provide this communication documentation or a physician's order to discontinue the Heparin flush.

An unannounced Home Health Agency recertification survey was conducted on March 29-30, 2021 by one (1) Medical Facilities Inspector 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 not to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on personnel file review and staff interview, it was determined the agency's Emergency Preparedness Plan (EPP) failed to contain documentation of agency staff demonstrating their knowledge of emergency procedures. The findings: The agency's EPP and six personnel files were reviewed in the agency on 3/29/2021 with the Administrator. The Medical Facilities Inspector (MFI) reviewed the six staff members personnel files for EPP training which contained an attestation that was signed and dated for EPP training by the staff members. On 3/29/2021 at 1:30 p.m. the Administrator stated, "We give them a handout and video on emergency preparedness but no test or quiz like that." The personnel files failed to contain evidence of the staff's knowledge on emergency procedures. The lack of the above noted training information was reviewed with the Administrator and Clinical Manager prior to and during the exit conference on 3/30/2021.

An unannounced Home Health Agency recertification was conducted March 29-30, 2021 by one MFI (Medical Facilities Inspector) from The Office of Licensure and Certification, Virginia Department of Health. The survey occurred both onsite and remotely due to the COVID-19 Public Health Emergency. The agency reported 186 unduplicated admissions in the last twelve (12) months. The agency was found not to be in compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs) and deficiencies were cited.

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 review of clinical records, staff interview and a home visit, it was determined the agency failed to ensure all patients' individualized plans of care included all medications in two (2) of seven (7) clinical records reviewed in the survey sample. Specifically, the agency failed to include oxygen on the patient's medication list. Clinical records: #1 and #6). The findings: Seven clinical records were reviewed on 3/29/2021 with read only access with the following findings: 1. The clinical record for Patient #1 contained documentation in the nurse's visit note dated 3/17/2021 that the patient used 2.5 Liters of oxygen via nasal cannula at night. The care plan for the certification period 3/11/2021-5/9/2021 failed to contain documentation of the oxygen and related supplies on the medication list or on the list of patient required supplies. 2. The clinical record for Patient #6 contained documentation in the nurse's visit notes dated 3/10/2021, 3/12/2021, 3/17/2021 and 3/19/2021 that the patient used 3 Liters of oxygen via nasal cannula. The care plan for the certification period 3/1/2021-4/29/2021 failed to contain documentation of the oxygen and related supplies on the medication list. On 3/30/2021 at 10:00 a.m. the Medical Facilities Inspector asked the Administrator and Clinical Manager if they were aware of the above noted patients oxygen use since it was not listed on the medication list. The Administrator and Clinical Manager confirmed and agreed with the above noted findings. In addition the Medical Facilities Inspector conducted a home visit on 3/30/2021 at 11:30 a.m. with Patient #6 and observed the patient using oxygen at 3 Liters per minute via nasal cannula. The failure to document oxygen as a medication on the patients medication list was acknowledged prior to and during the exit conference with the Administrator and Clinical Manager during the exit conference conducted on 3/30/2021.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on review of clinical records and staff interview it was determined the agency failed to ensure each patient's care followed the physician's orders on the plan of care for one (1) out of seven (7) clinical records in the survey sample (Clinical record # 6). The findings: Seven clinical records were reviewed on 3/29/2021 with read only access with the following findings: 1. The clinical record for Patient #6 was reviewed for the time frame of 3/11/2021 - 5/9/2021. The plan of care contained physician orders to cleanse/irrigate the left femoral, right clavicle and midsternal with saline, apply gauze and cover with mefix tape with SN (Skilled Nurse) visits at two (2) times a week for two (2) weeks. The clinical record contained documentation of SN visits on 3/17/2021 and 3/25/2021 with no wound care documentation. In addition, the clinical record only contained documentation on the wounds on the start of care (3/11/2021) that read as follows: wounds unable to observe surgical dressing. On 3/30/2021 at 10:00 a.m. the Medical Facilities Inspector asked the Administrator and Clinical Manager if they were aware of no wound care documentation for the above patient. The Administrator and Clinical Manager confirmed and agreed with the above noted findings. The Clinical Manager called and texted the SN who made the above visits and questioned the wound assessment. The Clinical Manager reported to the Medical Facilities Inspector that the SN who visited the patient texted, it was an incision site that was healed and documented in the assessment. The Administrator and Clinical Manager were unable to find this assessment and both stated, the nurse should have documented it and sent an order to the physician to discontinue wound care. The lack of providing a treatment ordered by the physician was acknowledged prior to and during the exit conference with the Administrator and Clinical Manager on 3/30/2021.

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 review of clinical records and staff interview, it was determined the agency failed to send the patient's transfer summary to the physician within 2 business days of becoming aware of an unplanned transfer for three (3) of three (3) patients who were transfered and their clinical records were reviewed in the survey sample. (Clinical records: #2, #3 and #4). The findings: Three transfer clinical records were reviewed on 3/29/2021 with read only access with the following findings: 1. The clinical record for Patient #2 was transferred from the agency on 3/11/2021. The clinical record revealed a transfer summary was sent to the primary physician on 3/26/2021; 15 days later. 2. The clinical record for Patient #3 was transferred from the agency on 1/1/2021. The clinical record revealed a transfer summary was sent to the primary physician on 1/11/2021; 10 days later. 3. The clinical record for Patient #4 was transferred from the agency on 1/4/2021. The clinical record revealed a transfer summary was sent to the primary physician on 1/12/2021; 8 days later. On 3/30/2021 at 10:00 a.m. the Medical Facilities Inspector asked the Administrator and Clinical Manager if they were aware of the late transfer summaries for the above patients. The Administrator and Clinical Manager confirmed and agreed with the above noted findings. The lack of providing a transfer to the physician within 2 business days was acknowledged prior to and during the exit conference with the Administrator and Clinical Manager during the exit conference conducted on 3/30/2021.