Every finding on record at S&S Healthcare, Inc.

One (1) Medical Facilities Inspector (MFI) from the Office of Licensure and Certification (OLC), Virginia Department of Health (VDH) conducted an unannounced Home Health Medicare Recertification Survey on December 13 - 14, 2021. As part of the inspection process, the agency's Emergency Preparedness Plan was reviewed. The agency was found to be in compliance with 42 CFR 484.113, the Condition of Participation - Emergency Preparedness for Home Health Agencies.

One (1) Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health, conducted an unannounced Medicare/Medicaid home health recertification survey at the above-noted agency from December 13, 2021 to July 14, 2021. The agency reported 191 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of seven (7) patients, five (5) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver and two (2) home visits (agency had 2 active patients) and multiple staff interviews were conducted. 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.

At discharge CFR(s): 484.55(d)(3) At discharge. This ELEMENT is not met as evidenced by: Based on review of clinical records and staff interview, it was determined the agency failed to complete the discharge OASIS (Outcome and Assessment Information Set) for two (2) of five (5) discharged patients in the survey sample (Clinical records #4 and #6). The findings: Five (5) discharged clinical records were reviewed onsite on 12/14/2021 with read only access with the following findings: 1. The clinical record for patient #4 was reviewed for the certification period of 3/3/2021 to 5/1/2021. The record revealed that the patient was discharged from the agency on 4/22/2021. The record failed to contain documented evidence that a discharge OASIS (Outcome and Assessment Information Set) was completed. On 12/14/2021 at 11:50 AM the MFI (Medical Facilities Inspector) asked the Administrator for the discharge OASIS. The Administrator stated, Physical Therapist did not do it. 2. The clinical record for patient #6 was reviewed for the recertification period of 9/17/2021 to 11/15/2021. The record revealed that the patient was discharged from the agency on 10/4/2021. The record failed to contain documented evidence that a discharge OASIS was completed. On 12/14/2021 at 12:50 PM, the MFI requested the agency's policy and procedure regarding the agency's comprehensive assessment process from the Administrator. The Administrator provided the MFI with the policy titled "Discharge from Home Care" and read in part as follows: "The designated employee completes the discharge assessment for any patient/client who has received more than one visit: a) During the last visit; or b) Within 48 hours of discharge or knowledge of discharge. 10. The discharge assessment and related documentation are filed in the patient's/client's record. a) The comprehensive assessment is completed to accurately reflect the patient's status at the time of discharge". The lack of providing a discharge OASIS at the patient's discharge was acknowledged prior to and reviewed during the exit conference with the Administrator and Alternate Administrator on 12/14/2021.

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 a review of clinical records and interviews it was determined the agency staff failed to follow the individualized plans of care for two (2) of seven (7) patients in the survey sample (Clinical records #1 and #5). The findings: Seven (7) clinical records were reviewed onsite on 12/14/2021 with read only access with the following findings: 1. The clinical record for patient #1 was reviewed for the recertification period of 12/3/2021 to 1/31/2021. The plan of care for the above noted timeframe contained orders for Physical Therapy (PT) three (3) times a week for three (3) weeks. The clinical record contained a PT missed visit on 12/6/2021 with no documentation of why the visit was missed. The clinical record contained documentation of two (2) PT visits the week of 12/4/2021 through 12/10/2021 when three were ordered. The clinical record failed to contain documentation that the patient's physician was notified of the visit not being provided in accordance with the patient's plan of care. On 12/14/2021 at 9:00 AM the Administrator confirmed the missed visit and the failure to notify the physician. 2. The clinical record for patient #5 was reviewed for the certification period of 5/17/2021 to 7/15/2021. The plan of care for the above noted timeframe contained orders for Skilled Nurse (SN) three (3) times a week for four (4) weeks. The clinical record contained a SN missed visit on 5/31/2021 with no documentation of why the visit was missed. The clinical record contained documentation of two (2) SN visits the week of 5/29/2021 through 6/4/2021 when three were ordered. The clinical record failed to contain documentation that the patient's physician was notified of the visit not being provided in accordance with the patient's plan of care. On 12/14/2021 at 10:50 AM the Administrator confirmed the missed visit and the failure to notify the physician. The above noted findings were reviewed and was acknowledged by the Administrator and Alternate Administrator prior to and during the exit conference on 12/14/2021.

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 5 business days of the patient's discharge for two (2) of five (5) discharged patients in the survey sample (Clinical records #4 and #6). The findings: Five (5) discharged clinical records were reviewed onsite on 12/14/2021 with read only access with the following findings: 1. The clinical record for patient #4 was reviewed for the certification period of 3/3/2021 to 5/1/2021. The record revealed that the patient was discharged from the agency on 4/22/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. 2. The clinical record for patient #6 was reviewed for the recertification period of 9/17/2021 to 11/15/2021. The record revealed that the patient was discharged from the agency on 10/4/2021. The record failed to contain documented evidence that a discharge summary was sent to the primary physician. On 12/14/2021 at 12:40 PM the MFI (Medical Facilities Inspector) asked the Administrator for the discharge summary to the physician. The Administrator stated, it was not done. On 12/14/2021 at 12:50 PM, the MFI requested the agency's policy and procedure regarding the agency's discharge process from the Administrator. The Administrator provided the MFI with the policy titled "Discharge from Home Care" and read in part as follows: "A copy of the discharge summary is provided to the primary physician or allowed practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge (if any) within 5 business days of the patient's discharge". The lack of providing a discharge summary within 5 business days of the patient's discharge was acknowledged prior to and reviewed during the exit conference with the Administrator on 12/14/2021.