Every finding on record at Pavilion Medical Home Care & Staffing, LLC

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted on August 22-24, 2022 and August 29, 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. 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 Medicare Medicaid recertification survey was conducted on August 22-24, 2022 and August 29, 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 1019 unduplicated admissions in the last twelve (12) months with an active census of 169 patients. The following were completed/reviewed in conjunction with the survey: Seven (7) home visits, seventeen (17) clinical records, five (5) personnel files, review of selected policies and procedures, the complaint log, the 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 staff interview and document review it was determined agency staff failed to ensure each patient participated in and was informed of the care in advance of treatment being furnished to include the visit frequency of all disciplines for three (3) of seventeen (17) clinical records reviewed in the survey sample (clinical records #1, 2, and 3). The findings were: The clinical records contained consent forms which list each discipline and contained an area for the proposed frequency for each discipline to be written in by the admitting clinician. 1. Clinical record #1 contained a signed consent form however, the admitting clinician put a check in the space for the disciplines that would be visiting the patient (occupational and physicial therapy) but failed to enter a visit frequency. 2. Clinical record #2 contained a signed consent form however, the admitting clinician circled the disciplines that would be visiting the patient (skilled nursing and physicial therapy) but failed to write the visit frequency. 3. Clinical record #3 contained a signed consent form however, the admitting clinician put a check in the space for the disciplines that would be visiting the patient (skilled nursing, physicial therapy and occupational therapy) but failed to write the visit frequency. The findings were reviewed with the administrator, staff member #2 and the Director of Operations, staff member #1 during record review and again at the exit conference.

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on an interview and review of clinical records it was determined the agency failed to ensure patients received all the services ordered in the plan of care for two (2) of seventeen (17) clinical records in the survey sample (clinical records #10 and 16). Specifically, the plan of care contained orders for an evaluation by the Occupational therapist (OT) and the OT never completed and or documented an evaluation. The findings were: 1. Clinical record #10 was reviewed for the certification period of 7/08/2022 through 9/05/2022. The plan of care contained physician orders for Occupational Therapy (OT) to evaluate and treat. The clinical record contained no evidence of an OT evaluation. The findings were presented to the administrator (staff member #2), Director of Operations (staff member #1) and the Office Manager (staff member #3) at approximately 9:30 am on 8/24/2022. At approximately 3:30 pm the Office Manager, staff member #3 provided a verbal order stating, OT services were not needed however, the order was dated the day of the survey (8/24/2022) and had not been signed by the physician. 2. Clinical record #16 was reviewed for the certification period of 6/20/2022 through 8/18/2022. The plan of care contained physician orders for Occupational Therapy (OT) to evaluate and treat. The clinical record contained no evidence of an OT evaluation. The findings were presented to the administrator (staff member #2), Director of Operations (staff member #1) and the Office Manager (staff member #3) at approximately 9:30 am on 8/24/2022. At approximately 3:30 pm the Office Manager, staff member #3 provided a verbal order stating OT services were not needed. The physician's order was dated the day of the survey (8/24/2022) and had not been signed by the physician.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on document review it was determined the agency failed to ensure each patient was advised in advance of providing care the extent to which payment for HHA (home health agency) services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, the charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, and the charges the individual may have to pay before care is initiated in seventeen (17) of seventeen (17) clinical records reviewed in the survey sample (clinical records #1-17). The findings were: The electronic clinical records and paper consents for treatment were reviewed from 8/22/2022 through 8/24/2022 and on 8/29/2022. The consents for treatment for all seventeen (17) clinical records revewed contained a blanket statement titled authorization for payment which stated, if the patient had Medicare part A benefits, Medicare will be accepted as payment in full however, the form was not specific about payment for other insurance providers. Specifically, the form stated "If I have other insurance, I may be responsible for the co-payment and any charges that my insurance will not cover. I will refer to the rates for service provided by the agency for the maximum dollar amounts that I may be required to pay. I understand that I am responsible for all amounts not paid by insurance. If I am a private pay patient, I agree to pay for all services rendered by the agency." The form failed to contain a place to document what the payor source was for each patient and if the patient had any financial liability for payment. The findings were reviewed with the administrator, staff #2 and the director of operations, staff #1, prior to and during the exit interview on 8/29/2022.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to ensure each patient received proper written notice, in advance of a specific service being furnished, if the HHA believed that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. Specifically, the agency failed to provide written, advance notice prior to discontinuing nursing service to one (1) of seventeen (17) patients in the survey sample (clinical record #16). The findings were: Clinical record #16 was reviewed for the certification period of 6/20/2022 through 8/18/2022. The plan of care contained physician orders for skilled nursing care two (2) times per week for one week and one (1) time per week for eight (8) weeks. The skilled nurse stopped seeing the patient on the second week of services. The clinical record failed to contain evidence the patient was notified in advance of nursing services being discontinued. The findings were presented to the administrator (staff member #2), Director of Operations (staff member #1) and the Office Manager (staff member #3) at approximately 9:30 am on 8/24/2022. At approximately 3:30 pm the Office Manager, staff member #3 reported being unable to locate a signed notice of Medicare non-coverage (NOMNC)

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 staff interview and clinical record review it was determined the agency failed to conform with physician orders. Specifically, the agency failed to follow the plan of care visit frequency for disciplines seeing the patient for four (4) of seventeen (17) patients in the survey sample (clinical records #1, 6, 16, and 17). The findings were: 1. Clinical record #1 was reviewed for the certification period of 6/11/2022 through 8/09/2022. The plan of care contained physician orders for physical therapy (PT) services one (1) time per week for one (1) week, two (2) times per week for two (2) weeks and one (1) time per week for six (6) weeks. The PT failed to make a second visit during weeks two and three (6/12/2022 and 6/19/2022). An interview with the Office Manager (staff member #3) on 8/24/2022 at approximately 3:25 PM revealed it was a staffing issue and they were unable to staff the case. The patient was transferred to another agency on 6/24/2022. There was no evidence in the clinical record that the physician was notified of the change in the plan of care. 2. Clinical record #6 was reviewed for the certification period of 7/21/2022 through 9/18/2022. The plan of care contained physician orders for a home health aide to visit two (2) times a week for four (4) weeks. The aide did not start seeing the patient until 8/09/2022, twenty days after the physician's order and plan of care were created. The aide only made one (1) visit and has not been back to see the patient. No aide visits were made the week of 7/21/2022, 7/24/2022, 7/31/2022 or 8/14/2022. An interview with the Office Manager (staff member #3) on 8/24/2022 at approximately 3:25 PM revealed it was a staffing issue. There was no evidence in the clinical record that the physician was notified of the change in the plan of care. 3. Clinical record #16 was reviewed for the certification period of 6/20/2022 through 8/18/2022. The plan of care contained physician orders for skilled nursing services, two (2) times per week for one (1) week and one (1) time per week for eight (8) weeks. The skilled nurse failed to conduct a second visit the first week of services (6/20/2022). The clinical record failed to contain documentation as to the reason for the missed visit. Additionally there was no evidence in the clinical record that the physician was notified of the change in the plan of care. 4. Clinical record #17 was reviewed for the certification period of 8/01/2022 through 9/29/2022. The plan of care contained physician orders for Occupational Therapy (OT) services two (2) times per week for two (2) weeks and one (1) time per week for three (3) weeks. The OT failed to conduct a second visit the first week of care (8/01/2022) and the clinical record failed to contain documentation as to the reason for the missed visit. There was no evidence in the clinical record that the physician was notified of the change in the plan of care.

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 staff interview and clinical record review it was determined the agency failed to ensure all services and treatments were administered only as ordered by a physician in two (2) of seventeen (17) clinical records reviewed in the survey sample (clinical records #8 and 14). The findings were: 1. Clinical record #8 was reviewed for the recertification period of 7/13/2022 through 9/10/2022. A review of the plan of care revealed the patient had a diagnosis of a pressure ulcer to the right buttock. The plan of care contained no wound care orders. A review of the skilled nursing notes dated, 7/13/2022, 7/15/2022, 7/17/2022, 7/20/2022, 7/21/2022, 7/25/2022 and 7/27/2022 revealed the skilled nurse was performing wound care to include cleaning the wound with normal saline, using santyl on the wound bed, and covering the wound with gauze and mepilex. 2. Clinical record #14 was reviewed for the certification period of 7/20/2022 through 9/17/2022. A review of clinical notes revealed the nurse saw the patient on 7/20/2022. The plan of care contained no orders for skilled nursing. The physician order section of the clinical record contained no verbal order's for skilled nursing services. The findings for the above clinical records were presented to the administrator (staff member #2), Director of Operations (staff member #1) and the Office Manager (staff member #3) at approximately 9:30 am on 8/23/2022. No physician orders was presented to the surveyor by the exit interview of 8/29/2022.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observations and interviews it was determined the agency staff failed to follow infection control guidelines when performing wound care for one (1) of one (1) wound care observed during home visits (the patient with clinical record #9). The findings were: A home visit was conducted with the skilled nurse (staff member #4) on 8/24/2022 at 11:30 AM and Patient #9 in the survey sample. The patient had wounds on the left foot and the visit was to observe the nurse performing wound care. The nurse (staff member #4) failed to set up a clean area with supplies prior to beginning wound care. The nurse pulled the box of wound care supplies over within reach of where the nurse would be sitting to perform wound care. The nurse sat on a stool at the end of the patient's bed and removed the old dressing and cleaned the wound. Throughout the course of wound care, the nurse, staff member #4 consistently would remove one (1) glove and without performing hand hygiene, don a clean glove and continue with the wound care. The nurse was not consistent in which glove was removed whether it was right or left. In addition, the nurse continuously reached into the box of clean supplies to get gauze as needed, normal saline, betadine and mepilex. This process continued repeatedly throughout the wound care process with the innumerable glove changes and reaching in the box of clean supplies as the patient had three wounds on the foot and they needed to be soaked prior to redressing. On one occasion it was observed that the nurse had betadine on the glove when reaching into the clean packet of gauze after cleaning the wound. During the wound care process, the skilled nurse only removed both gloves and performed hand hygiene on two occasions. One of those times was when the nurse stopped to rub lotion on the patient's lower leg and the other was when wound care was completed. An interview was conducted with the marketer (staff member #5) immediately following the visit. Staff member #5 was not present for the visit and unaware of the normal procedure for doing wound care. Staff member #5 acknowledged the nurse failed change both gloves each time and perform hand hygiene as well as the nurse reached into the box of clean supplies multiple times with dirty hands/gloves. Fundamentals of Nursing Mosby, Potter and Perry, 7th Edition St. Louis Missouri, page 645 states in part: modes of transmission for infection are indirect contact-personal contact of susceptible host with contaminated inanimate object (e.g.,needles or sharp objects, dressings, environment). In this case, the gloves would have been contaminated after touching the dressing and wound and both should have been changed each time with hand hygiene performed when going from a dirty to clean area. Page #655 goes on to discuss medical asepsis or clean technique procedures are used to reduce the number of organisms present and prevent the transfer of organisms. According to the Centers for Disease Control and Prevention (CDC), hand hygiene should be performed after contact with nonintact skin, after contact with wound dressings, and after removing gloves. (Guideline for Hand Hygiene in Health-Care Settings. Retrieved from https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf). The nurse placed the patient at risk for infection by not following standards of practice to prevent infection transmission and failing to perform hand hygiene at the required times.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on staff interviews and document review it was determined the agency failed to ensure at least one qualifying skilled service was provided directly through agency employees. During the entrance conference on 8/22/2022 at 11:30 am, the Director of Operations stated Occupational therapy (OT) services were provided directly. A review of the clinical records revealed five (5) patients with OT names listed in the record that were not on the employee roster (direct employees) that was presented to the surveyor. An interview was conducted with the administrator (staff member #2) on 8/29/2022 at 1:30 PM. The administrator stated one (1) of the therapist listed was hard to get to take a case and the others were from a contract agency. The administrator stated they no longer work with that staffing agency. A follow-up interview was conducted with the administrator (staff member #2), director of operations (staff member #1), and marketer (staff member #4), at approximately 3:30 PM on 8/29/2022. The marketer identified mid-June as the date the agency quit working with the contract agency. The director of operations and this surveyor explained to the administrator that even though technically only one OT was employed by the agency at this time and the employee was a direct employee of the agency, the agency was using a combination of contracted staff and direct hire staff for all skilled services as recently as June 2022. The Medicare form 1572 was revised by the director of operations, staff member #2 to reflect that all skilled services were either contracted or a combination of contracted and directly employed by the agency.