Every finding on record at Medi Home Health Agency, Inc.

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted July 25-27, 2022 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. Deficiencies were identified and cited in this report. The agency was found to be out of compliance with 42 CFR 484.102 Conditions of Participation Emergency Preparedness for Home Health Agencies

HHA Comprehensive Assessment in Disaster CFR(s): 484.102(b)(1) §484.102(b)(1) Condition for Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (1) The plans for the HHA's patients during a natural or man-made disaster. Individual plans for each patient must be included as part of the comprehensive patient assessment, which must be conducted according to the provisions at §484.55. This STANDARD is not met as evidenced by: Based on a review of agency documents, observations during home visits and staff interview it was determined the agency failed to ensure staff developed individualized emergency preparedness plans as part of the comprehensive assessment for thirteen (13) of thirteen (13) patients whose clinical records were reviewed in the survey sample (clinical records #1-13). The admission packet was reviewed in the agency on 7/25/2022 at approximately 11 am. The packet contained a patient care handbook which included a form titled Evacuation Planning. The form contained sections to fill out with the patient's demographic information, emergency contact information, what the patient plans to do in relation to evacuation in a disaster, the type of assistance the patient would need and medical care information. The electronic records were reviewed from 7/25/2022 through 7/27/2022 in read only mode. A review of the clinical records revealed no evidence of the above described Evacuation plan having been completed or any type of individualized emergency preparedness plan for thirteen (13) of thirteen (13) clinical records reviewed. Home visits were conducted to four (4) patients on 7/26/2022 (patient's #7, 8, 9, and 10). A review of the admission packet in each patient's home revealed the form for Evacuation plan had not been completed. No other type of individualized emergency preparedness plan could be located in the home. An interview was conducted with the administrator, staff member #1 on 7/26/2022 at 1:20 PM. The administrator stated, the staff should be filling out the evacuation form on admission. A review of the policy titled "Emergency Management Plan" states in part: Individual emergency management plan instructions given to the patient/family/caregiver should be documented in the patient's medical record, and is included as part of the comprehensive patient assessment.

An unannounced Medicare Medicaid Home Health Agency recertification survey was conducted July 25-27, 2022 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 411 unduplicated admissions in the last twelve (12) months with an active census of 53 patients. The following were completed/reviewed in conjunction with the survey: Four (4) home visits, thirteen (13) clinical records, seven (7) personnel files, review of selected policies and procedures, the agency's complaint log, emergency preparedness plan, and Covid vaccination records. Interviews were also conducted. Deficiencies were identified and cited in this report. 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 clinical record review it was determined the agency failed to ensure patients were informed at the time of admission of the disciplines that would provide care and the frequency of visits for two (2) of thirteen (13) patients in the survey sample (clinical records #6 and 10). The electronic clinical records were reviewed from 7/25/2022 through 7/27/2022 in read only mode. 1. Clinical record #6 was reviewed for the certification period of 7/06/2022 through 9/03/2022. The clinical record failed to contain evidence of the patient and/or caregiver having received documentation of the disciplines providing care and the frequency of planned visits prior to receiving care. The patient was to receive skilled nursing services. 2. Clinical record #10 was reviewed for the certification period of 7/12/2022 through 9/09/2022. The clinical record failed to contain evidence of the patient and/or caregiver having received documentation of the disciplines providing care and the frequency of planned visits prior to receiving care. The patient was to receive skilled nursing, physical therapy, occupational therapy and social work services. The findings were reviewed with the administrator, staff member #1 and the clinical manager, staff member #2 prior to and during the exit conference on 7/27/2022.

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 , observations made during home visits and an interview it was determined the agency staff failed to ensure plans of care contained all the required elements to include an accurate and complete list of medications and treatments for two (2) of thirteen (13) patients in the survey sample (clinical records #1 and 9) The electronic clinical records were reviewed from 7/25/2022 through 7/27/2022 in read only mode. 1. Clinical record #1 was reviewed for the certification period of 10/05/2021 through 12/03/2021. The patient was on Oxygen however, the plan of care orders failed to contain the amount and frequency of use for the oxygen. The order was written as, "Supplemental oxygen for L (liter) per minute via nasal cannula for COPD (chronic obstructive pulmonary disease. A review of the clinical record revealed staff were documenting the patient as being on 2, 3 or 4 liters of oxygen at different visits so it is unclear if the orders were for a range of 2-4 liters. The agency staff that includes skilled nursing, physical therapy and occupational therapy were also not documenting if the patient was using the oxygen continuously or as needed. 2. Clinical record #9 was reviewed for the certification period of 7/12/2022 through 9/09/2022. The plan of care contained an order in the medication section for, "Santyl external 250 unit/GM 1 apply to left heel topically". The plan of care contained no further information on a wound to the left heel. A review of the clinical record revealed no evidence the patient had a wound on the left heel. A home visit was conducted with the nurse to patient #9 on 7/26/2022. The nurse, staff member #3 revealed the patient did not have a heel wound and that the Santyl topical was being used on a coccyx wound. The nurse stated the patient had a heel wound during a previous admission which was now healed. An interview conducted with the administrator, staff member #2 on 7/27/2022 at 8:45 AM revealed the plan of care/medication list was inaccurate and should have listed the coccyx wound and not the heel. The findings related to patient #1 and the oxygen were shared with staff members #1 and #2 at that time and again during the exit conference.

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 interviews it was determined the agency staff failed to follow the plan of care for three (3) of thirteen (13) patients in the survey sample (clinical record #4, 6 and 7). Specifically, the staff failed to follow wound care instructions and visit frequencies. The electronic clinical records were reviewed on 7/25/2022 through 7/27/2022 in read only mode. 1. Clinical record #4 was reviewed for the certification period of 4/07/2022 through 8/04/2022. The plan of care contained orders for wound care to the left heel, clean with soap and water, pat dry, apply Medihoney, bordered guaze and secure lightly with Coban. A review of skilled nursing notes on 5/03/2022, 5/06/2022, 5/13/2022, 5/17/2022, 5/24/2022, 6/03/2022, 6/06/2022, 6/09/2022, 6/13/2022, 6/16/2022, 6/20/2022, 6/23/2022, 6/27/2022 and 6/30/2022 revealed no documented evidence the nurses were using Coban to secure the dressing. There was nothing documented in the record to reflect what was being used to secure the dressing. 2. Clinical record #6 was reviewed for the certification period of 7/06/2022 through 9/03/2022. The plan of care contained orders for wound care to the right heel to include; clean wound with normal saline, apply skin prep to surrounding area, apply Medihoney and hydrofera blue to wound bed, cover with foam dressing. A review of the wound care addressed/treatment section of skilled nursing notes on 7/15/2022, 7/19/2022, 7/22/2022 and 7/25/2022 revealed no hydrofera blue was used on the wound bed. The notes on 7/15/2022, 7/19/2022, 7/22/2022 stated, hydrofera blue was not used, not in supply. An interview with the clinical manager, staff member #2 was conducted on 7/27/2022 at 9:45 AM. Staff member #2 did not know why the patient did not have hydrofera blue. The staff member stated that they have had supply issues but did not know if that was one of the supplies. 3. Clinical record #7 was reviewed for the certification period of 6/09/2022 through 8/07/2022. The plan of care called for occupational therapy (OT) visits two (2) times per week for three (3) weeks then one (1) time per week for three (3) weeks. During the week of 7/10/2022 when the OT should have made one visit for the week, no visit was made/documented. The clinical record failed to contain a note documenting the missed visit and there was no evidence the physician was notified of the missed visit. An interview with the clinical manager, staff member #2 was conducted on 7/27/2022 at 9:45 AM. The staff member was unable to figure out why a visit was missed but thought it was a scheduling problem.

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 an interview it was determined the agency's staff performed care without obtaining a physicians order for one (1) of thirteen (13) patients in the survey sample (clinical record #8). Specifically, the staff applied a three layer compression dressing to a wound without a physicians order. The electronic clinical records were reviewed on 7/25/2022 through 7/27/2022 in read only mode. Clinical record #8 was reviewed for the certification period of 6/15/2022 through 8/13/2022. The plan of care contained orders for wound care to BLE (bilateral lower extremities) to perform Unna boot applications twice weekly as follows: cleanse with NS (normal saline), pat dry, from mid foot to just below the knee, wrap zinc oxide impregnated gauze, then wrap with kerlix, and finally secure with Coban. A review of the skilled nursing notes revealed the nursing staff began documenting the use of three layer compression dressing in addition to the Unna boot without a physician's order. Skilled nursing notes on 6/20/2022, 6/23/2022, 6/27/2022 and 7/05/2022 documented the use of the three layer compression dressing. An interview was conducted with the administrator, staff member #1 and the clinical manager, staff member #2 to review the findings on 7/27/2022 at 8:45 AM. The staff members were to review the record and check for additional orders. Staff member #2 was interviewed a second time on 7/27/2022 at 9:45 AM and stated, "I don't know why that became part of the verbiage, it shouldn't have been".