Every finding on record at Interim Healthcare of Roanoke

An unannounced Home Health Agency recertification survey was conducted on June 27-30, 2023 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 June 27-30, 2023 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 901 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, (17) clinical records and six (6) personnel files were reviewed. Seven (7) home visits were conducted. 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.

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 a complete and accurate wound vac order with dressing treatment ordered by the physician for one (1) of two (2) patients in the survey sample whom had a wound vac (Clinical record: #1). The findings: Seventeen electronic clinical records were reviewed in read only mode from June 28-29, 2023. The clinical record for patient #1 was reviewed for the certification period of 02/10/2023 to 04/10/2023. The plan of care contained a narrative as follows: not observable wound to mid chest. wound vac (vacuum-assisted closure of a wound) @ 12mmhg d/t non-removable dressing (non-healing surgical wound). The plan of care order failed to instruct skilled nursing on how to manage and treat the wound with the wound vac. In addition, the clinical record contained skilled nursing documentation of wound care as follows: 02/13/2023-"Wound care performed today as ordered using clean technique." The wound was measured and contained documentation of purulent drainage, cleaned with normal saline and packed with granulofoam. 02/16/2023-"Cleansed wound to midchest (surgical) with dermal cleanser. Applied black foam to midchest and tunneling at 6 o'clock at 125 mmHg. Pt (patient) tolerated wound care well." 02/17/2023-"Pressure of wound vac fluctuates and won't stay on 125 mmHg, no leakage message observed to machine, changed the whole Dsg (dressing) again, seems like problem solved. No fluctuated pressure observed." 02/21/2023-"Wound care performed today as ordered using clean technique." The wound was measured and contained documentation of purulent drainage to Mid sternum, cleaned with normal saline and packed with granulofoam. 02/23/2023-"Wound care performed today as ordered using clean technique." The wound contained documentation of purulent drainage to Mid sternum, cleaned with normal saline and packed with granulofoam. 02/24/2023-"Dressing removed, wound cleansed as ordered with ordered wound cleanser. Area dried completely, foam inserted and pressure dressing applied." 03/03/2023-"Patient was seen by her MD and they placed a wet to dry dressing until we could come out to replace wound vac dressing. Wound care performed today as ordered. Washed wound with wound cleanser, dried with sterile gauze and replaced the wound vac using clean technique." 03/06/2023-"Wound care performed today as ordered using clean technique." On 06/29/2023 at 11:50 PM, an interview was conducted with the Regional Operations Manager regarding the incomplete wound vac orders on the plan of care. The Regional Operations Manager acknowledged the lack of specifics of the wound vac on the plan of care and the incorrect wound pressure setting. The Regional Operations Manager provided the MFI with wound care orders dated 02/07/2023 from a skilled nursing facility from a physician that read as follows: "Clean open surgical incision over midline from cheat [sic] with NS (Normal Saline), pat/dry, then apply Wound vac dressing at 125 mmHg, continuously and change dressings twice a week." The MFI explained this order was not found in the physician order software and the order provided from 02/07/2023 did not specify what the wound vac dressing were. The clinical record failed to contain specific wound vac orders.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical records review and staff interview, it was determined the agency failed to ensure the physician was notified of the patient's condition that may suggest outcomes are not being met or changes are needed in the plan of care for one (1) of (17) clinical records in the survey sample (Clinical record # 16). The findings: Seventeen electronic clinical records were reviewed in read only mode from June 28-29, 2023. The clinical record for patient #16 was reviewed for the certification period of 03/07/2023 to 05/05/2023. The patient's plan of care contained orders for SN (Skilled Nurse) one (1) time a week for one (1) week and two (2) times a week for eight (8) weeks. SN to assess vital signs at every visit, notify MD (Medical Doctor) if outside of established parameters. Instruct patient/caregiver on home monitoring of the following vital signs and when to notify HHA (home health agency)/MD. Assess vital signs at every visit. Temperature of (more than) 100.5. The clinical record failed to contain documentation of notifying the physician of patient's temperature revealed by the following: Specific details: 03/16/2023-under the title "Vital Signs" the SN documented a temperature of 101.7 The SN documented in the narrative notes as a slight fever and the patient's daughter was aware. The failure to alert physician to changes that suggest a need to alter the plan of care was reviewed with the Office Manager and Regional Operations Manager during the record review and again at the exit conference on 06/30/2023.

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 interview, it was determined the agency failed to send the patient's discharge summary to the primary care physician or primary care practitioner within 5 business days from the date of the final visit and failed to send the patient's transfer summary within 2 business days of becoming aware of an unplanned transfer. In addition, the discharge and transfer summaries should contain laboratory data, medication the patient is taking at time of discharge, and patient/family post-discharge instructions for five (5) of five (5) closed clinical records reviewed in the survey sample. (Clinical record #'s 1, 2, 3, 4 and 16). The findings: Five closed, electronic clinical records were reviewed in read only mode from June 28-29, 2023. The clinical record for patient #1 was reviewed for the certification period of 02/10/2023 to 04/10/2023. The clinical record revealed that the patient was transferred from the agency on 03/09/2023. The transfer summary was sent to the primary physician on 03/09/2023 but did not include the components of any laboratory data or medications the patient was taking. On 06/29/2023 at 11 AM, the Regional Operations Manager stated, "we send the discharge/transfer OASIS (Outcome and Assessment Information Set)." The MFI (Medical Facilities Inspector) reviewed the above patient's OASIS which did not include the laboratory data if any or the medications the patient was taking at time of transfer. The clinical record for patient #2 was reviewed for the certification period of 03/28/2023 to 05/26/202. The clinical record revealed that the patient was transferred from the agency on 04/18/2023. The transfer summary was sent to the primary physician on 06/29/2023;72 days later and did not include the components of any laboratory data or medications the patient was taking. On 06/29/2023 at 11:40 AM, the Regional Operations Manager stated, "The software needs to be updated for transfer summary elements." The clinical record for patient #3 was reviewed for the certification period of 05/19/2023 to 07/17/2023. The clinical record revealed that the patient was discharged from the agency on 05/25/2023. The discharge summary was sent to the primary physician on 06/08/2023;14 days later. The clinical record for patient #4 was reviewed for the certification period of 01/07/2023 to 03/07/2023. The clinical record revealed that the patient was discharged from the agency on 02/10/2023. The discharge summary was sent to the primary physician on 02/20/2023;10 days later. The clinical record for patient #16 was reviewed for the certification period of 03/07/2023 to 05/05/2023. The clinical record revealed that the patient was discharged from the agency on 04/13/2023. The discharge summary was sent to the primary physician on 04/21/2023;8 days later. The lack of providing a discharge summary within 5 business days of the patient's discharge and a transfer within 2 business days with needed elements was acknowledged prior to and during the exit conference with the Office Manager and Regional Operations Manager on 06/30/2023.