Every finding on record at Prima Home Health Inc

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted on August 15-16, 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.

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 staff interview and document review it was determined the agency failed to ensure an up to date all hazards risk assessment had been completed for the agency. The findings were: A review of the agency's emergency preparedness plan (EPP) on 8/15/2022 revealed the risk assessment completed failed to contain an all hazard approach. The tool utilized by the agency was limited in scope and failed to address all hazards the agency may face for its geographic location to include natural and manmade disasters. An interview conducted with the administrator, staff #1 at the entrance conference on 8/15/2022 at 11:10 am revealed the agency suffered a ransomware attack in March 2022 and lost the EPP plan that was saved on the computer. No printed copy was available and the agency had to rewrite the EPP plan.

Local, State, Tribal Collaboration Process CFR(s): 484.102(a)(4) §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility's needs in the event of an emergency. This STANDARD is not met as evidenced by: Based on staff interview and document review it was determined the agency failed to develop and maintain an emergency preparedness plan (EPP) that included a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials'. Efforts on how to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts were not presented at the time of the review. The findings were: A review of the agency's emergency preparedness plan (EPP) on 8/15/2022 revealed no evidence the agency had a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation, including documentation of the facility's efforts to contact such officials and, when applicable, of its participation in collaborative and cooperative planning efforts. An interview conducted with the administrator, staff #1 at the entrance conference on 8/15/2022 at 11:10 am revealed the agency suffered a ransomware attack in March 2022 and lost the EPP plan that was saved on the computer. No printed copy was available and the agency had to rewrite the EPP plan.

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's emergency preparedness policies and procedures failed to contain a current communication plan that included contact information for federal, state, tribal, regional and local emergency preparedness (EPP) staff. The findings were: A review of the agency's emergency preparedness plan (EPP) revealed the agency failed to have a communication plan that included the contact information for federal, state, tribal, regional and local emergency preparedness staff. An interview conducted with the administrator, staff #1 at the entrance conference on 8/15/2022 at 11:10 am revealed the agency suffered a ransomware attack in March 2022 and lost the EPP plan that was saved on the computer. No printed copy was available and the agency had to rewrite the EPP plan.

Primary/Alternate Means for Communication CFR(s): 484.102(c)(3) §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID's staff, Federal, State, tribal, regional, and local emergency management agencies. This STANDARD is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means for communicating with staff, Federal, state, regional and local emergency management agencies. The findings were: A review of the agency's emergency preparedness plan revealed the agency failed to develop and maintain an emergency preparedness communication plan that included a primary and alternate means for communicating with staff, Federal, state, regional and local emergency management agencies. An interview conducted with the administrator, staff #1 at the entrance conference on 8/15/2022 at 11:10 am revealed the agency suffered a ransomware attack in March 2022 and lost the EPP plan that was saved on the computer. No printed copy was available and the agency had to rewrite the EPP plan.

EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on an interview and a review of agency documents it was determined the agency failed to provide initial training in emergency preparedness policies and procedures that would be consistent with their role(s) in an emergency. Specifically, documentation was not found in sixteen (16) of sixteen (16) personnel files reviewed in the survey sample (staff #16-21). The findings were: The personnel files were reviewed in the agency on 8/16/2022 at 12:30 PM. The personnel files for all sixteen (16) records reviewed failed to contain evidence of initial emergency preparedness training. An interview with the administrator, staff #1 at approximately 1:10 PM revealed the orientation checklist has emergency preparedness listed as evidence of training. A review of the orientation checklist had a listing for "emergency call procedure" but did not state it was emergency preparedness and the record did not contain evidence of what was included in the training.

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted on August 15-16, 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 11 unduplicated admissions in the last twelve (12) months with an active census of 51 patients. The following were completed/reviewed in conjunction with the survey: Three (3) home visits, seven (7) clinical records, sixteen (16) personnel files, the review of selected policies and procedures, the complaint log, the emergency preparedness plan and, COVID vaccination records. Interviews were als 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).

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 a review of clinical records it was determined that agency staff failed to follow the plan of care for six (6) of six (6) patients whose records were reviewed in the survey sample (clinical records #2-7). Specifically, the hours and frequency of skilled nursing and personal care aide visits did not follow the plan of care. The findings were: The clinical records were reviewed in the agency on August 15-16, 2022. Clinical record #2 was reviewed for the certification period of 08/05/2022 through 10/04/2022. The plan of care was for skilled nursing, 16 hours per day, 7 days per week. The patient was actually only receiving services for 12 hours per day. An interview with the administrator at 1:15 PM on 8/16/2022 revealed the family did not want the nurse in the home for 16 hours but the type of insurance coverage the patient has requires the agency to maintain the 16 hour care plan they are entitled to. If the hours are reduced and the patient needs the hours later, they would not be able to get them back. The agency failed to document the reason for the reduction in service in the clinical record and there was no evidence the physician was aware of the change in the plan of care. Clinical record #3 was reviewed for the time frame of 7/10/2022 through 8/12/2022. The plan of care was for personal care services, 8 hours per day, 7 days per week. The patient failed to receive services on 7/12/2022, 7/14/2022, 7/15/2022, 7/16/2022, 8/01/2022, 8/07/2022, 8/08/2022, 8/09/2022 and 8/13/2022. An interview with the clinical manager, staff #2 at 1:15 PM on 8/16/2022 revealed staffing issues were the reason for the missed visits. The agency failed to document communication with the family in the clinical record. Clinical record #4 was reviewed for the certification period of 7/01/2022 through 12/31/2022. The plan of care was for skilled nursing, 12 hours per day, 7 days per week. The skilled nurse only provided care for 4 hours on Tuesdays (7/5/2022, 7/13/2022, 7/19/2022 and 7/26/2022). An interview with the administrator at 1:15 PM on 8/16/2022 revealed the family only wanted 4 hours on Tuesdays. The agency failed to document that communication and the family's wishes in the clinical record. There was no evidence the physician was aware of the change in the plan of care. Clinical record #5 was reviewed for the certification period of 7/18/2022 through 9/17/2022. The plan of care was for skilled nursing, up to 7 hours per day, 4-5 days per week. The patient only received skilled services three days per week the 1st, 2nd and 4th week of the certification period. The dates of services for those weeks were; 7/18/2022, 7/20/2022, 7/25/2022, 7/27/2022, 7/29/2022 8/08/2022, 8/10/2022 and 8/12/2022. An interview with the administrator at 1:15 PM on 8/16/2022 revealed the family chooses the days they want nursing to come however, that was not documented in the clinical record. There was no evidence the physician was aware of the change in the plan of care. Clinical record #6 was reviewed for the time period of 1/24/2022 through 3/23/2022. The plan of care was for personal care services, 12 hours per day, 7 days per week. The patient only received 10 hours of service on the following Saturdays and Sundays- 1/29/2022, 1/30/2022, 2/19/2022, 2/20/2022, 2/26/2022, 2/27/2022, 3/04/2022 and 3/05/2022. An interview with the administrator at 1:15 PM on 8/16/2022 revealed the family would often send the aide home early and the aide should document that in the notes however, it was not documented. Clinical record #7 was reviewed for the time period of 3/28/2022 through 6/08/2022. The plan of care was for personal care services, 8 hours per day, 7 days per week. The patient failed to receive services on most Saturdays during the time period reviewed and multiple Sundays were also missed. The dates missed were 4/02/2022, 4/16/2022, 4/17/2022, 4/23/2022, 4/24/2022, 5/07/2022, 5/08/2022, 5/14/2022, 5/21/2022, and 5/28/2022. An interview with the administrator at 1:15 PM on 8/16/2022 revealed there were staffing issues with the weekend and the family was aware however, the agency failed to document that in the clinical record.

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 staff interview and a review of clinical records it was determined the agency failed to complete a discharge summary for two (2) of two (2) discharged patients whose records were reviewed in the survey sample (clinical records #6 and 7). The findings were: The clinical records were reviewed in the agency on 8/15/2022 through 8/16/2022. Clinical record #6 was reviewed for the time period of 1/24/2022 through 3/23/2022. The patient was discharged on 3/25/2022. The clinical record failed to contain a discharge summary. Clinical record #7 was reviewed for the time period of 3/28/2022 through 6/08/2022. The patient was discharged on 6/08/2022. The clinical record failed to contain a discharge summary. An interview conducted with the administrator, staff #1 and the clinical manager, staff #2 on 8/16/2022 at 1:15 PM revealed they were unaware a discharge summary was needed.