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

An unannounced Home Health Agency recertification survey was conducted on March 24-26, 2025, 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 March 24-26, 2025, by one Medical Facilities Inspector 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. Deficiencies were identified and cited in this report.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on clinical record review and interview, it was determined the agency failed to conduct a timely resumption of care within 48 hours of a patient's return home from a hospital admission of more than 24 hours for one (1) of one (1) patient who had a resumption of care whose clinical record was reviewed as part of the survey sample: (Clinical record for Patient: #3). The clinical record for patient #3 was reviewed for the certification of December 27, 2024 to February 24, 2025. The clinical record indicated the patient being transferred to the hospital on February 12, 2025 and was discharged home February 16, 2025. The resumption of care (ROC) was completed by the skilled nurse on February 20, 2025 (4 days later). On March 26, 2025 at 12 PM, Staff Member #7 revealed the agency failed to provide timely initiation of care. The agency failed to complete the ROC within 48 hours of the patient's return home from the hospital.

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 interview it was determined the agency staff failed to ensure the plan of care contained the specific location of a wound and the order of the wound for one (1) of three (3) patients in the survey sample who had a wound: (Clinical record for Patient #4). The clinical record for patient #4 was reviewed for the recertification of November 03, 2024 to January 01, 2025. The plan of care indicated a primary diagnosis of lymphedema (swelling and accumulation of lymph fluid in legs). The clinical record indicated skilled nurse visited the patient one (1) time a week for six (6) weeks with Unna boot (multilayered elastic compression dressing with zinc oxide paste wrapped from the toes to the knees) to legs bilaterally at every visit. On March 26, 2025 at 12 PM, Staff Member #7 revealed the wound order did not get pushed to the new certification period. The plan of care failed to include the wound order and location(s).

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency 01/19-27/2020 by a Medical Facilities Inspector from the office of Licensure and Certification, Virginia Department of Heath. In conjunction with this survey the agency's emergency preparedness plan was reviewed. The agency was found not to be in compliance with 42 CFR 484.113 Conditions of Participation Emergency Preparedness for Home Health Agencies effective 11/15/2017.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on document review and staff interview, it was determined the agency failed to develop an emergency preparedness plan based on a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach to include strategies for addressing emergency events identified by the risk assessments. Findings: The agency's emergency preparedness plan was reviewed in the agency on 01/20/2021 with the Administrator with the following findings: The agency failed to develop an emergency preparedness plan based on a documented, facility-based and community-based risk assessments, utilizing an all-hazards approach to include strategies for addressing emergency events identified. The lack of the above noted information was reviewed with Administrator prior to and during the exit conference on 01/27/2021.

Emergency Officials Contact Information CFR(s): 484.102(c)(2) §403.748(c)(2), §416.54(c)(2), §418.113(c)(2), §441.184(c)(2), §460.84(c)(2), §482.15(c)(2), §483.73(c)(2), §483.475(c)(2), §484.102(c)(2), §485.68(c)(2), §485.625(c)(2), §485.727(c)(2), §485.920(c)(2), §486.360(c)(2), §491.12(c)(2), §494.62(c)(2). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. *[For LTC Facilities at §483.73(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) The State Licensing and Certification Agency. (iii) The Office of the State Long-Term Care Ombudsman. (iv) Other sources of assistance. *[For ICF/IIDs at §483.475(c):] (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. (iii) The State Licensing and Certification Agency. (iv) The State Protection and Advocacy Agency. This STANDARD is not met as evidenced by: Based on staff interview and document review it was determined the agency failed to document an Emergency Preparedness Communication Plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following: (2) Contact information for the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. Findings: The agency's emergency preparedness plan was reviewed in the agency on 01/20/2021 with the Administrator and failed to document when the Communication Plan was reviewed and updated on the following: (i) Federal, State, tribal, regional, and local emergency preparedness staff. (ii) Other sources of assistance. The Administrator acknowledged the above noted findings during the exit conference on 01/27/2021.

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted facility on January 19-27, 2021 by one Medical Facilities Inspector from the Office of Licensure and Certification (LOC). The agency identified (398) unduplicated admissions in the last twelve (12) months. The agency has no branches. The records of (10 patients, (5) employees, the complaint log, agency's Admission Packet, various selected Policies and Procedures were reviewed. Fve (5) patient home visits were conducted. One patient refused a home visit but agreed to a telepone interview. The facility failed to be in compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies (Revised 01/13/2018).

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 staff interview and document review it was determined the agency failed to ensure the patient was informed prior to services being provided of the following: disciplines that will furnish the care, frequency of visits, and the financial cost and responsibility of these services for four (4) of ten (10) patient records reviewed in the survey sample. Patient Records: 3, 4, 5, and 8. Findings: Ten (10) patient records were reviewed on 01/20-27/2021 with the following findings: 1. Patient record #3 with a start of care of 01/09/2021 was reviewed for the time frame of 01/09/2021-01/23/2021. The patient's informed consent (a consent signed at the time of admission) failed to contain a frequency of proposed visits and the patient's financial liability. 2. Patient record #4 with a start of care of 04/15/2020 was reviewed for the time frame of 12/01/2020 to 01/21/2021. The patient's informed consent contains the following wording," I agree to pay any charges not covered by insurance benefit plans excluding Medicare and Medicaid recipients and where payment is prohibited by law." The patient failed to sign this section. 3. Patient record #5 with a start of care date of 12/20/2020 was reviewed for the time frame of 12/20/2020 to 01/31/2021. The patient's informed consent failed to identify which discipline would provide services, the approximate cost of those services, and the amount the patient may have to pay. The informed consent also contains a statement which reads, " The undersigned certifies that he/she is not currently receiving services under the Medicare Home Health Benefit from another licensed certified HHA. The patient failed to sign this statement. 4. Patient record #8 with a start of care date of 12/20/2020 was reviewed for the time frame of 12/20/2020 to 01/31/2021. The patient's informed consent failed to identify which discipline would provide services, the approximate cost of those services, and the amount the patient may have to pay. The lack of completing all required blanks on the above noted informal consents was reviewed with the administrator on 01/27/2021.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on staff interview and document review it was determined the agency's information in their admission packet regarding patient's having the right to file a complaint failed to contain the following: state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs (home health agencies) for ten (10) of ten (10) patient records reviewed in the survey sample. Patient Records: 1, 2, 3, 4, 5, 6, 7, 8 , 9, and 10. Findings: The agency's admission packet given to the patient at the time of admission to home health was reviewed in the agency on January 19, 2021. At the top of page 5 the following was documented: " Rights and Responsibilities" at the bottom of page 5 the following was documented, " Be advised of the availability, hours of operation and purpose of the State Home Health Agency Hotline. The purpose of this hot-line is to receive complaints and questions regarding local home health agencies." At the top of page 34 of the admission packet titled " Patient Concerns and Grievance Process" a diagram is displayed regarding how a complaint is handled once received by the agency. The first box reads, " Call your Home Health Agency. "Monday -Friday 8 am-PM." The name and telephone of the agency Administrator failed to appear on this page. 1. Patient record #1 with a start of care date of 12/11/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 2. Patient record #2 with a start of care date of 09/10/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 3. Patient record #3 with a start of care date of 01/09/2021 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 4. Patient record #4 with a start of care date of 04/15/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 5. Patient record #5 with a start of care date of 12/19/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 6. Patient record #6 with a start of care date of 12/14/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 7. Patient record #7 with a start of care date of 10/22/2020 was reviewed on 01/22/2021 and failed to contain the above noted written blocks of instruction and information regarding how to lodge a complaint. 8. Patient record #8 with a start of care date of 12/18/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 9. Patient record #9 with a start of care date of 10/03/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint. 10. Patient record #10 with a start of care date of 06/13/2020 was reviewed on 01/22/2021 and failed to contain the above noted written squares of instruction and information regarding how to lodge a complaint The lack of the above noted information on page 34 was reviewed with the Administrator who acknowledged her name was missing. In addition, the state toll free home health hot line number, its contact information, the hours of operation, and that its purpose is to receive complaints or questions about local HHAs were also not documented.