Every finding on record at Nine Palms 1, L.L.C

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency 06/06/2022 to 06/08/2022 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 on at the above noted agency on 06/06/2022 to 06/08/2022 by two (2) Medical Facilities Inspectors from the Virginia Department of Health, Office of Licensure and Certification. The agency operates one (1) CMS (Centers for Medicare/Medicaid Services) approved branch in addition to the parent office. The survey was conducted at the parent location. The branch location was toured by the Medical Facilities Inspector on 06/07/2022. Branch location: 6606 Main Street Gloucester, VA 23061 In conjunction with the survey, the following were reviewed: seventeen (17) clinical records, incorporating records of patients from the parent and branch office, twelve (12) personnel files, COVID-19 vaccination requirement, agency admission packet, complaint log, organizational chart, and CLIA (Certified Laboratory Improvement Amendments) waiver. Seven (7) home visits and multiple staff interviews were conducted. The facility was found not to be in compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. Deficiencies were identified and cited.

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 document review and staff interview it was determined the agency failed to ensure that each patient was informed in advance of providing care of the proposed visit frequency of disciplines providing care for two (2) of seventeen (17) clinical records reviewed in the survey sample (Clinical records #1 and #10). Findings: Seventeen (17) clinical records were reviewed in the agency on 06/07/2022 and 06/08/2022 with the following findings: 1. The clinical record of patient #1 with a start of care date of 05/22/2022 was reviewed in the agency on 06/07/2022. The clinical record contained a form titled, “Patient Acknowledgement and Consents”, which is included in the patient’s admission packet and is used to notify the patient of disciplines that will furnish care and the proposed frequency of visits. The Proposed Disciplines and Frequencies section of the form failed to contain the proposed visit frequency of disciplines that would furnish care. A check mark was documented instead of the proposed visit frequency. 2. The clinical record of patient #10 with a start of care date of 01/15/2022 was reviewed in the agency on 06/07/2022. The clinical record contained a form titled “Patient Acknowledgement and Consents”, which is included in the patient’s admission packet and is used to notify the patient of disciplines that will furnish care and the proposed frequency of visits. The Proposed Disciplines and Frequencies section of the form failed to contain the proposed visit frequency of disciplines that would furnish care. A check mark was documented instead of the proposed visit frequency. The failure to notify the patients in advance of providing care of the proposed visit frequency of disciplines that would furnish care was acknowledged by the Administrator during the clinical record reviews and again during the exit conference conducted in the agency on 06/08/2022.

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 include all medications currently used by patient on the patient's medication profile/plan of care for five (5) of seventeen (17) clinical records in the survey sample (Clinical records #2, #6, #10, #12 and #15) Findings: Seventeen (17) clinical records were reviewed in the agency on 06/07/2022 and 06/08/2022 with the following findings: 1. The clinical record for patient #2 was reviewed for the certification period of 05/05/2022 to 07/03/2022. The record revealed on the start of care visit 05/05/2022 the patient was on 2 liters of oxygen via nasal cannula. The patient’s medication profile and the medication section of the patient’s plan of care failed to include oxygen as noted above. 2. The clinical record for patient #6 was reviewed for the certification period of 01/21/2022 to 03/21/2022. The record revealed on the start of care visit 01/21/2022 the patient was on 2 liters of oxygen via nasal cannula. The patient’s medication profile and the medication section of the patient’s plan of care failed to include oxygen as noted above. 3. The clinical record for patient #10 was reviewed for the certification period of 01/15/2022 to 03/15/2022. The record revealed on physical therapy visit 02/09/2022 the patient was now using two (2) liters of oxygen at night. The patient’s medication profile failed to include oxygen as noted above. 4. The clinical record for patient #12 was reviewed for the certification period of 05/12/2022 to 07/10/2022. The record revealed on the start of care visit 05/12/2022 the patient was on 2 liters of oxygen via nasal cannula. The patient’s medication profile and the medication section of the patient’s plan of care failed to include oxygen as noted above. 5. The clinical record for patient #15 was reviewed for the certification period of 05/07/2022 to 07/05/2022. The record revealed on the start of care visit 05/07/2022 the patient was on 2 liters of oxygen via nasal cannula. The patient’s medication profile and the medication section of the patient’s plan of care failed to include oxygen as noted above. Policy Review The agency’s policy titled, “Drug Regimen Review” was reviewed in the agency on 06/08/2021. Select portions read as follows: The clinician completing the OASIS Assessment must complete a comprehensive drug regimen review of all medications the patient is currently taking at the time of admission, recertification, resumption of care and with any major change in condition. The medication profile is completed by documenting: All the patient’s medications which include: Medications on written prescriptions and medication bottles Over-the-counter medications Herbal Products Vitamins and Supplements Oxygen The Administrator acknowledged agency staff failed to include oxygen on the medication profile/plan of care during the clinical record reviews and again during the exit conference conducted in the agency on 06/08/2022.

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 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 within five (5) business days of discharge and/or failed to send a transfer summary within two (2) business days as required for three (3) of five (5) discharge records in the survey sample (Clinical records #6, #7 and #10). Findings: Seventeen (17) clinical records were reviewed in the agency on 06/07/2022 and 06/08/2022 with the following findings: 1. The clinical record for patient #6 was reviewed for the certification period of 01/21/2022 to 03/21/2022. The record revealed a discharge date of 02/21/2022. The clinical record failed to contain evidence the patient’s discharge summary was sent to the physician within five (5) business days of discharge. 2. The clinical record for patient #7 was reviewed for the certification period of 02/21/2022 to 04/21/2022. The record revealed a discharge date of 03/15/2022. The clinical record failed to contain evidence the patient’s discharge summary was sent to the physician within five (5) business days of discharge. 3. The clinical record for patient #10 was reviewed for the certification period of 01/15/2022 to 03/15/2022. The record revealed the patient was transferred to an inpatient facility on 03/13/2022. The clinical record failed to contain evidence a transfer summary was sent within two (2) business days. Also, the clinical record revealed the patient was discharged from home health services on 03/15/2022. The clinical record failed to contain evidence the patient’s discharge summary was sent to the physician within five (5) business days of discharge. During the clinical record reviews on 06/08/2022 the Medical Facilities Inspector (MFI) requested evidence discharge summaries were sent to the physician within five (5) business days of discharge and transfer summary within two (2) business days. The Administrator provided fax confirmations for the parent location but was unable to provide evidence for the branch location. The Administrator stated the branch location was unable to provide evidence. He she/stated, “They didn’t do it”. The Administrator acknowledged the agency failed to send a discharge summary to the patient’s physician within five (5) business days and/or transfer summary within two (2) business days as required during the clinical record reviews and again during the exit conference conducted in the agency on 06/08/2022.