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

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on July 18-20, 2022 by two (2) Medical Facilities Inspectors 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 18-20, 2022 by two (2) Medical Facilities Inspectors from the Virginia Department of Health Office of Licensure and Certification. The agency reported 664 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of (13) patients, (10) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, vaccination rule and five (5) home visits were conducted and or reviewed. Multiple staff interviews were also conducted. The agency operates a branch location and a visit was made to the site on July 19-20, 2022. The branch address is: 11832 Rock Landing Drive Ste 110, Newport News VA 23606. 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.

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 and staff interview 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 nine (9) of (13) patients in the survey sample (Clinical records #’s 1, 2, 4, 5, 6, 7, 10, 11 and 13). The findings: Thirteen electronic clinical records were reviewed onsite in read only mode July 19-20, 2022. 1. The informed consent signed at the time of admission and prior to services being provided for patient #1 with a start of care date of 06/22/2021 failed to contain documentation of the frequency of Skilled Nursing services the patient would be receiving. 2. 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 06/02/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 3. 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 06/10/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 4. The informed consent signed at the time of admission and prior to services being provided for patient #5 with a start of care date of 06/12/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 5. 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 06/28/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 6. 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 12/17/2021 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 7. The informed consent signed at the time of admission and prior to services being provided for patient #10 with a start of care date of 03/20/2022 failed to contain documentation of the frequency of Skilled Nursing, Physical Therapy and Occupation Therapy services the patient would be receiving. 8. The informed consent signed at the time of admission and prior to services being provided for patient #11 with a start of care date of 02/04/2022 failed to contain documentation of the frequency of Skilled Nursing and Physical Therapy services the patient would be receiving. 9. The informed consent signed at the time of admission and prior to services being provided for patient #13 with a start of care date of 07/09/2022 failed to contain documentation of the frequency of Skilled Nursing and Occupational Therapy services the patient would be receiving. The lack of documentation at the time of admission and prior to services being provided regarding the frequency of services to be provided was reviewed with the Administrator, Clinical Manager and Regional Administrator prior to and during the exit conference on 07/20/2022.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure that each patient received home health services as ordered by the physician/non-physician practitioner in the patient's individualized plan of care for one (1) of (13) clinical records in the survey sample (Clinical record #9). The findings: Thirteen electronic clinical records were reviewed onsite in read only mode July 19-20, 2022. 1. The clinical record of patient #9 was reviewed for the certification period 12/31/2021 to 02/28/2022. According to the patient's plan of care (POC), the physician ordered Skilled Nursing (SN) services with a frequency of one (1) time a week for one (1) week then three (3) times a week for eight (8) weeks and two (2) prn (as needed) visits for wound complications. The POC contained a physician's order for wound orders: Skilled Nurse to instruct caregiver to cleanse external fixator pin sites with cotton tipped applicator dipped in peroxide and wrap with kerlix once a day and twice a day if sites are red. SN to perform during nursing visits and caregiver all other times. The clinical record contained SN documentation of the pin sites cleaned with 1/2 normal saline and 1/2 peroxide on 01/15/2022 and 01/28/2022. The POC also contained a physician's order for another wound order to the right ischium pressure injury: Cleanse with DWC (dermal wound cleanser), pat dry, apply medihoney, calcium alginate and a dry dressing. SN to complete during nursing visits, caregiver to perform prn soiling and when SN is not present. The clinical record contained SN documentation of calmoseptine applied to the right ischium open wound with measurements of 1 x 0.25 x 0.1. The clinical record failed to contain documentation that wound care was provided as ordered above. On 07/20/2022 the Clinical Manager confirmed the Medical Facilities Inspector's findings and stated, there was no evidence of orders to change the wound care. The clinical record also contained a physician's order for Skilled Nurse (SN) to obtain a PT/INR on 01/26/2022. The clinical record failed to contain documentation a SN visit was made on 01/26/2022 to obtain a PT/INR as ordered by the physician. The clinical record contained documentation PT/INR wasn't obtained by SN until 01/28/2022. The clinical record failed to contain documentation as to why PT/INR wasn't obtained on 01/26/2022 as ordered by the physician or that the physician was notified of the delay. On 07/20/2022 the Clinical Manager confirmed the Medical Facilities Inspector's findings and stated, there was no new orders obtained to change the PT/INR date. In addition, the clinical record contained physician's order to notify physician of: Pulse less than 55. On 01/28/2022 the clinical record contained documentation of the patient's pulse of 52. The clinical record failed to contain documentation that the patient's pulse was reported to the physician as ordered. On 07/20/2022 the Clinical Manager confirmed the Medical Facilities Inspector's findings and stated, the physician was not notified of the low heart rate. The above noted findings were acknowledged by the Administrator, Clinical Manager and Regional Administrator during the clinical record reviews and again during the exit conference conducted in the agency on 07/20/2022.

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 staff interview it was determined the agency failed to ensure wound care and treatments were administered only as ordered by a physician for one (1) of (13) clinical records in the survey sample (Clinical record: #8). The findings: Thirteen electronic clinical records were reviewed onsite in read only mode July 19-20, 2022. 1. The clinical record for patient #8 was reviewed for the certification period of 11/15/2021 to 01/13/2022. The primary diagnosis on the patient's plan of care (POC) was Barrett's esophagus without dysplasia. The clinical record contained documentation of a new wound to the right and left great toe on 11/22/2021. The Skilled Nurse (SN) documented the toes were cleansed with dwc (dermal wound cleanser), patted dry, applied iodine soaked gauze to toes then secured with kerlix on the dates of 11/22/2022, 11/26/2022, 11/30/2022, 12/07/2022, and 12/15/2022. On 07/19/2022, the Medical Facilities Inspector requested evidence of a physician's order for the wound care provided on the above dates. On 07/20/2022, the Clinical Manager stated, the clinician called for wound care orders on 11/22/2022 but were not placed in the system. The above noted findings regarding agency's staff failure to obtain wound care orders were reviewed with the Administrator, Clinical Manager and Regional Administrator prior to and during the exit conference on 07/20/2022.

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 five (5) of five (5) closed clinical records reviewed in the survey sample. (Clinical record #'s 3, 7, 8, 9 and 10). The findings: Four closed, electronic clinical records were reviewed onsite in read only mode July 19-20, 2022. 1. The clinical record for patient #3 was reviewed for the certification period of 06/13/2022 to 10/27/2021. The clinical record revealed that the patient was transferred from the agency on 7/15/2022. The transfer summary was sent to the primary physician on 07/20/2022; 3 business days later. 2. The clinical record for patient #7 was reviewed for the certification period of 12/17/2021 to 02/14/2022. The clinical record revealed that the patient was discharged from the agency on 01/13/2022. The discharge summary was sent to the primary physician on 01/25/2022; 12 days later. 3. The clinical record for patient #8 was reviewed for the certification period of 11/15/2021 to 01/13/2022. The clinical record revealed that the patient was discharged from the agency on 01/13/2022. The discharge summary was sent to the primary physician on 02/01/2022; 19 days later. On 07/20/2022 the Clinical Manager confirmed the Medical Facilities Inspector's findings and stated, the discharge summary was not sent to the doctor within 5 days. 4. The clinical record for patient #9 was reviewed for the certification period of 12/31/2021 to 02/28/2022. The clinical record revealed that the patient was discharged from the agency on 02/24/2022. The discharge summary was sent to the primary physician on 03/15/2022; 18 days later. On 07/20/2022 the Clinical Manager confirmed the Medical Facilities Inspector's findings and stated, the discharge summary was not sent to the doctor within 5 days 5. The clinical record for patient #10 was reviewed for the certification period of 03/20/2022 to 05/18/2022. The clinical record revealed that the patient was discharged from the agency on 03/22/2022. The discharge summary was sent to the primary physician on 04/01/2022; 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 Administrator, Clinical Manager and Regional Administrator on 07/20/2022.