Every finding on record at Medi Home Health Agency, Inc

An unannounced Home Health Agency recertification survey was conducted on December 13-15, 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 to be in compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies.

An unannounced Home Health Agency recertification survey was conducted on December 13-15, 2021 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 563 unduplicated admissions in the last twelve (12) months with an active census of 94 patients. The following were completed/reviewed in conjunction with the survey: Five (5) home visits, thirteen (13) clinical records, six (6) personnel files, review of selected policies and procedures, complaint log, emergency preparedness plan and interviews were conducted.The agency was found to be out of compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs).

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 interviews and document review, it was determined the agency failed to ensure that patients were informed about and consented to the disciplines and/or frequency of proposed visits in advance of starting care in six (6) of thirteen (13) clinical records reviewed in the survey sample (clinical record #'s 5, 9, 10, 11, 12, and 13). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from December 13-15, 2021. Clinical record #5 was reviewed for the certification period of 11/02/2021 through 12/31/2021. The consent for care failed to contain the discipline and frequency of services to be provided. Clinical record #9 was reviewed for the recertification period of 11/03/2021 through 1/01/2022. The consent for care failed to contain the discipline and frequency of services to be provided. Clinical record #10 was reviewed for the certification period of 11/17/2021 through 1/15/2022. The consent for care failed to contain the frequency of services to be provided. Clinical record #11 was reviewed for the certification period of 10/24/2021 through 12/22/2021. The consent for care failed to contain the frequency of services to be provided. Clinical record #12 was reviewed for the certification period of 11/29/2021 through 1/27/2022. The consent for care failed to contain the discipline and frequency of services to be provided. Clinical record #13 was reviewed for the certification period of 11/04/2021 through 1/02/2022. The consent for care failed to contain the discipline and frequency of services to be provided. The administrator was interviewed on 12/15/2021 at approximately 9 AM and acknowledged the above noted findings.

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 a review of clinical records and staff interview it was determined the agency failed to ensure services were provided as ordered by a physician for one (1) of thirteen (13) clinical records reviewed in the survey sample (clinical record #3). The findings were:The electronic clinical records were reviewed both onsite and offsite in read only mode from December 13-15, 2021. Clinical record #5 was reviewed for the certification period of 5/22/2021 through 7/20/2021. The plan of care/physician orders contained a primary diagnosis of Type 1 Diabetes with skilled nursing interventions to include but not limited to: SN (skilled nurse) to assess blood sugar log every visit and discuss abnormalities /out of range results with patient. The skilled nursing notes for the certification period contained no evidence the nurse had been assessing the blood sugar log for seven (7) weeks until 7/06/2021 when the patient's blood sugar registered 500 and the patient was transferred to the hospital. An interview was conducted with the administrator on 12/15/2021 at 8:35 AM. The administrator stated there was no evidence of blood sugar documentation other than on admission, the 7/06/2021 visit and the resumption of care after the hospital stay.

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 a review of clinical records and staff interview it was determined the agency failed to ensure services were provided only as ordered by a physician for one (1) of thirteen (13) clinical records reviewed in the survey sample (clinical record #13). The electronic clinical records were reviewed both onsite and offsite in read only mode from December 13-15, 2021. Clinical record #13 was reviewed for the certification period of 11/04/2021 through 1/02/2022. The skilled nurse made a visit on 11/23/2021 and documented performing a PICC line (peripherally inserted central catheter) dressing change. The plan of care failed to contain physician orders for the dressing change. The administrator was interviewed on 12/15/2021 at approximately 9 AM and acknowledged the above noted findings.