Every finding on record at Seven Hills Home Health Inc

An unannounced Medicare/Medicaid Home Health recertification survey was conducted at the above noted agency on March 28-30, 2022 by one (1) Medical Facilities Inspector 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 at the above noted agency on March 28-30, 2022 by one (1) Medical Facilities Inspector from the Virginia Department of Health Office of Licensure and Certification. The agency reported 598 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of (14) patients, (10) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver, and the vaccination rule were all reviewed. Five (5) home visits were conducted and multiple staff interviews were also 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

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 a review of clinical records and staff interview, it was determined the agency failed to ensure patients were informed at the time of admission of the proposed frequency of visits for two (2) of (14) patients whose records were reviewed in the survey sample (Clinical records: #5 and #11). The findings: Fourteen clinical records were reviewed in the agency on 3/30/2022 with the Administrator as the navigator. The consents for the patients listed below failed to contain evidence of the patient and/or caregiver having received documentation of the proposed frequency of planned visits. The consents had a section titled, "frequency" however the clinician hand wrote "SOC" (start of care) or left it blank for the discipline(s). 1. The clinical record for patient #5 with a documented start of care date of 2/18/2022 contained physician orders on the plan of care for, skilled nursing visits one (1) time a week for one (1) week and then three (3) times a week for one (1) week. The consent contained a frequency with a hand written note that read SOC. No frequency was recorded for services to be provided. 2. The clinical record for patient #11 with a documented start of care date of 3/8/2022 contained physician orders on the plan of care for, skilled nursing visits one (1) time a week for one (1) week and three (3) times a week for two (2) weeks. The consent contained a frequency that was left blank. The lack of documentation regarding informing the patient of the proposed visit frequencies was acknowledged by the Administrator during the clinical record reviews on 3/30/2022 and was reviewed with the Administrator during the exit conference conducted on 3/30/2022. .