Every finding on record at Lhcg Cxcviii, LLC

An unannounced Medicare/Medicaid Home Health complaint survey was conducted at the above noted agency November 28-29, 2023 by three (3) Medical Facilities Inspectors 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. A deficiency unrelated to the complaint was identified and cited in this report.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to ensure a Registered Nurse provided complete written patient care instructions for the home health aide in one (1) of three (3) applicable records reviewed in the survey sample. Medical record #2. Specifically, the written instructions for the aide indicated a frequency of "prn" without further instructions on when to perform specific patient care tasks. Seven (7) medical records were reviewed in the agency 11/28/23 - 11/29/23. Three (3) of the medical records reviewed were of patients who received home health aide services. The clinical record for patient #2 contained a document, Aide Care Plan Report that listed the following tasks for the aide to perform: vital signs, medication reminders, bathing, shampoo, perineal care, foot care, dressing, applying lotion, applying deodorant, brush hair, gather oral supplies, clean nails and make bed. All of these tasks were marked with a frequency of every visit and prn (as needed). The instructions to the aide did not provide further information related to when the prn tasks should be performed. An interview was conducted with staff member #5 on 11/29/23. Staff member #5 stated that they were responsible for creating aide care plans and that an aide care plan should not include tasks with a "prn" frequency as the aide cannot make the decision of when to perform the task. Staff member #5 stated that all aide care plans should be as clear and specific as possible. The surveyors requested the agency's policy related to home health aide care plans on 11/28/23. The agency provided a policy, Plan of Care that reads in part: An aide plan of care will be developed by the Registered Nurse or other appropriate skilled professional....If allowed per state regulation, that is familiar with the patient if aide services have been ordered. The policy failed to address the content of the aide plan of care and did not have any information related to frequencies in the care plan.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on July 17-19, 2023 and July 25-26, 2023 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 July 17-19, 2023 and July 25-26, 2023 by one (1) Medical Facilities Inspector from the Virginia Department of Health, Office of Licensure and Certification. The agency reported 765 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of (21) patients, (10) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, seven (7) home visits, and multiple staff interviews were 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.

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 staff interview and document review, it was determined the agency failed to ensure the patient received proper written notice, in advance of a specific service being furnished in advance of the HHA reducing or terminating on-going care. Specifically, the agency failed to provide written, advanced notice prior to discharging patients due to terminating services in the patient's geographical location for three (3) of five (5) patient records reviewed of patients with agency discharges within the agency's terminating location (Client record #'s 9, 18 and 20). Findings: Ten discharge/closed electronic clinical records were reviewed in the agency from 07/17-07/26/2023 via read only access. Five (5) of these discharged records were of patients who lived in a specific geographical location whereas the agency terminated services. Three (3) out of five (5) records of patients who lived in the specific location failed to contain evidence the patient was provided written notice in advance notifying the patient of discharge. 1. The clinical record for patient #9 contained a documented date of discharge of 06/12/2023 due to transferred to another home health agency. A HHCCN (Home Health Change of Care Notice) was noted in the clinical record with a date of 06/13/2023 that read as follows: Agency is no longer providing services in your area. The HHCCN form was not signed by the patient as indicated to do so at the bottom of the page. On 07/18/2023, the Medical Facility Inspector (MFI) asked what home health agency did the patient go to. The Executive Director was not able to locate where the patient transferred to. The clinical record failed to contain evidence that the agency advised the patient with written/verbal, advance notice of discharge. On 7/18/2023 at 12:30 PM, the MFI asked what area was the agency not providing services to. The Executive Director stated, the Peninsula area as of 6/12/2023. The MFI requested three more discharge records to review from the Peninsula area. 2. The clinical record for patient #18 contained a documented date of discharge of 06/13/2023 due to goals met. A NOMNC (Notice of Medicare Non-Coverage) was noted in the clinical record with a date of 06/13/2023. The NOMNC form was signed by the patient on 6/12/2023. The clinical record failed to contain evidence that the agency advised the patient with written/verbal, advance notice of discharge. 3. The clinical record for patient #20 contained a documented date of discharge of 06/23/2023, however the last skilled visit was 6/13/2023. A HHCCN (Home Health Change of Care Notice) was noted in the clinical record with a date of 06/13/2023 that read as follows: Inadequate staffing. The HHCCN form was signed by the patient on the last skilled visit of 06/13/2023. The clinical record failed to contain evidence that the agency advised the patient with written/verbal, advance notice of discharge. The agency's policy located in the patient admission packet, Transfer & Discharge Policy partially reads as follows: "There may be times we will need to transfer you to another provider or discharge you from our services. You will be given advance notice of a transfer to another agency or discharge, except in case of emergency " The Executive Director and Business Manager acknowledged the above noted deficiency during the exit conference on 07/26/2023.

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 clinical record review and staff interview, it was determined the agency failed to ensure accurate and complete medication lists were documented in four (4) of (21) clinical records reviewed in the survey sample (Clinical record #'s 3, 5, 8 and 9). Findings: Twenty-one electronic clinical records were reviewed in the agency from 07/17-07/26/2023 via read only access. 1. The clinical record for patient #3 was reviewed for the period of 06/07/2023 to 08/05/2023. The clinical record contained a skilled nursing visit on 06/07/2023 that documented the patient was "on oxygen at 2 lpm". The medication list was reviewed and did not contain oxygen. 2. The clinical record for patient #5 was reviewed for the period of 06/21/2023 to 08/19/2023. The clinical record contained a skilled nursing visit on 06/21/2023 that documented the patient was "on oxygen at 2 lpm NC (nasal cannula) continuous". The medication list was reviewed and did not contain oxygen. 3. The clinical record for patient #9 was reviewed for the period of 06/06/2023 to 08/04/2023. The clinical record contained a skilled nursing visit on 06/06/2023 that documented the patient had a "PICC (catheter inserted through a peripheral vein to deliver medications) to the left brachial". The clinical record also contained skilled nursing notes of the PICC flushed with saline and heparin as follows: 06/09/2023 -"PICC L (left) brachial amount of normal saline flush 60 total cc. 30 right and 30 left. Heparin flush 50 units 5 cc each line." 06/12/2023 -"PICC L (left) brachial amount of normal saline flush 10 cc right line, 20 cc in left line. Heparin flush 5 cc each line. 50,000 units" On 07/26/2023 the Medical Facilities Inspector (MFI) asked the Executive Director if the agency had orders or a protocol for PICC usage. The Executive Director provided the MFI an example of a plan of care with PICC line flushes that read as follows: "Heparin 100 unit/ml intravenous solution. After saline final saline flush with lab draws and with medication administration". "Normal saline flush 0.9% injection syringe. Flush PICC line with 10 cc before and after medication administration and before and after lab draws done via PICC line". The Executive Director stated, "the nurse who developed the patient's (patient #9) plan of care is new and forgot to add that template for the PICC line." The medication list was reviewed and did not contain the above medications flushed through the PICC. 4. The clinical record for patient #17 was reviewed for the period of 06/04/2023 to 08/02/2023. The clinical record contained a skilled nursing visit on 06/04/2023 that documented the patient was "on oxygen at 2 lpm NC intermittent with moderate exertion". The medication list was reviewed and did not contain oxygen. The failure to update each patient's medication profile was reviewed with the Executive Director and Business Manager prior to and during the exit conference on 07/26/2023.

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 to contained the specific location of a wound and the order of a PICC (catheter inserted through a peripheral vein to deliver medications) line with it's routine maintenance as ordered by the physician for one (1) of three (3) patients in the survey sample whom had a wound/PICC line (Clinical record: #9). Findings: Twenty-one electronic clinical records were reviewed in the agency from 07/17-07/26/2023 via read only access. 1. The clinical record for patient #9 was reviewed for the period of 06/06/2023 to 08/04/2023. The plan of care contained a narrative the patient was referred to home care for assistance with managing infusions and PICC line as well as education for diabetes and wound care. The clinical record contained a skilled nursing visit on 06/06/2023 that documented the patient had a "PICC (catheter inserted through a peripheral vein to deliver medications) to the left brachial". The clinical record also contained skilled nursing notes of the PICC flushed with saline and heparin as follows: 06/09/2023 -"PICC L (left) brachial amount of normal saline flush 60 total cc. 30 right and 30 left. Heparin flush 50 units 5 cc each line." 06/12/2023 -"PICC L (left) brachial amount of normal saline flush 10 cc right line, 20 cc in left line. Heparin flush 5 cc each line. 50,000 units" On 07/26/2023 the Medical Facilities Inspector (MFI) asked the Executive Director if the agency had orders or a protocol for PICC usage. The Executive Director stated, "the nurse who developed the patient's (patient #9) plan of care is new and forgot to add that template for the PICC line." The plan of care failed to include the PICC order and the PICC treatments. In addition, the plan of care contained wound care orders that read as follows: Skilled nurse cleanse the wound with wound cleanser and then pack the wound with the aquacel AG rope and then covered with dry dex dressing with pad provided by the patient placed over both the taped using paper tape". The plan of care failed to include the wound location(s). The Executive Director acknowledged the lack of PICC order, and its routine maintenance and the location of the wound on the plan of care prior to and during the exit interview of 07/26/2023. A review of the record revealed the wound was located on left plantar foot.

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 for seven (7) of ten (10) closed clinical records reviewed in the survey sample. (Clinical record #'s 1, 6, 7, 8, 9, 10, and 20). Findings: Ten discharge/closed electronic clinical records were reviewed in the agency from 07/17-07/26/2023 via read only access. 1. The clinical record for patient #1 was reviewed for the certification period of 05/27/2023 to 07/25/2023.The clinical record revealed that the patient was discharged from the agency on 06/01/2023. The agency failed to provide a discharge summary to the primary physician. On 07/18/2023 the Executive Director stated, "The patient went to the doctor's office and they referred them to hospice. It is a non-billable case". 2. The clinical record for patient #6 was reviewed for the recertification period of 03/21/2023 to 05/19/2023. The clinical record revealed that the patient was discharged from the agency on 04/12/2023. The discharge summary was sent to the primary physician on 04/28/2023; 16 days later. 3. The clinical record for patient #7 was reviewed for the recertification period of 02/04/2023 to 04/04/2023. The clinical record revealed that the patient was transferred from the agency on 03/30/2023. The transfer summary was sent to the primary physician on 05/04/2023; 35 days later. 4. The clinical record for patient #8 was reviewed for the certification period of 06/04/2023 to 08/02/2023. The clinical record revealed that the patient was discharged from the agency on 06/30/2023. The discharge summary was sent to the primary physician on 07/10/2023; 10 days later. 5. The clinical record for patient #9 was reviewed for the certification period of 06/06/2023 to 08/04/2023. The clinical record revealed that the patient was discharged from the agency on 06/12/2023. The discharge summary was sent to the primary physician on 07/04/2023; 22 days later. 6. The clinical record for patient #10 was reviewed for the certification period of 02/09/2023 to 04/09/2023. The clinical record revealed that the patient was discharged from the agency on 02/21/2023. The discharge summary was sent to the primary physician on 04/30/2023; 67 days later. On 07/18/2023 at 1:40 PM the Business Manager stated, "It was late d/t failed fax but was hand delivered on April 30th". 7. The clinical record for patient #20 was reviewed for the certification period of 05/24/2023 to 07/22/2023. The clinical record revealed that the patient was discharged from the agency on 06/23/2023. The discharge summary was sent to the primary physician on 07/03/2023; 10 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 was acknowledged prior to and during the exit conference with the Executive Director and the Business Manager on 07/26/2023.