Every finding on record at Shenandoah Valley Home Health

The provider submitted notification of voluntary closure effective 11/15/2024 prior to release of survey An unannounced complaint (# 108450) survey was conducted from September 30, 2024 through October 4, 2024 by a Medical Facilities Inspector from the Virginia Department of Health (VDH), Office of Licensure and Certification (OLC). It was determined the agency was not in substantial compliance with the requirements of 42 CFR 484, the Medicare Conditions of Participation of Home Health Agencies.

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 clinical records review and interviews, it was determined the agency failed to provide services and treatments in accordance with physician orders for eight (8) out of nine (9) patients (Clinical Records, Patient # 1,2,4,5,6,7,8,9) Findings: 1.) The clinical record for Patient #1 was reviewed for the period of August 17, 2024 through October 15, 2024. The plan of care for Patient #1 indicated skilled nursing visits frequency of one (1) time a week for eight (8) weeks effective August 18, 2024. The plan of care included orders effective August 14, 2024 to notify physician if respirations are greater than 28 per minute and less than 14 per minute, and notify physician if weight is greater than 270lbs and less than 260lbs. HHA (Home Health Agency) failed to document weight during visits on August 23, 2024; August 29, 2024; September 05, 2024; September 12, 2024; September 18, 2024. HHA failed to document respirations during visits on August 29, 2024 and September 12, 2024. October 03, 2024 visit indicates Patient # 1's weight is 273lbs. The skilled nursing visit note did not include documentation of physician notification. The HHA failed to document patient's respirations, weight and provide notification to physician in accordance with the plan of care for Patient #1. 2.) The clinical record for Patient #2 was reviewed for the period of September 04, 2024 through November 02, 2024. The plan of Care for Patient #2 included the following physical therapy intervention effective September 04, 2024: physical therapist to assess for signs and symptoms of hypoglycemia (a condition in which the blood glucose level is lower than the standard range) and hyperglycemia (a condition in which the blood glucose level is higher than the standard range) and report any signs to Medical Doctor (MD). The HHA failed to document signs and symptoms of hypoglycemia and hyperglycemia for Patient #2 on September 10, 2024 and September 16, 2024. The HHA failed to assess for signs and symptoms of hypoglycemia and hyperglycemia in accordance with the plan of care for Patient #2. 3.) The clinical record for Patient #4 was reviewed for the period of August 29, 2024 through October 27, 2024. The plan of care for Patient #4 indicated the following medically necessary services effective September 04, 2024: skilled nursing and physical therapy. The plan of care indicated skilled nursing visit frequency one (1) time a week for nine (9) weeks, however no frequency schedule was identified for physical therapy. The clinical record for Patient #4 did not indicate physical therapy visits had been conducted. The missed visit form dated August 30, 2024, for a physical therapy evaluation indicated cancellation of care and that Patient #4 agreed to a visit between 2:00 PM and 3:00 PM and due to delay per physical therapist’s schedule, patient refused to reschedule. The HHA failed to provide physical therapy services in accordance with the plan of care for Patient #4. 4.) The clinical record for Patient #5 was reviewed for the period of August 03, 2024 through October 01, 2024. The plan of care for Patient #5 indicated skilled nursing visit frequency (1) time a week for eight (8) weeks and the following order: Notify physician if weight is greater than 215lbs or less than 205lbs. HHA (Home Health Agency) failed to document weight during visits on August 08, 2024; August 16, 2024; August 23, 2024; August 30, 2024; September 06, 2024; September 13, 2024; September 20, 2024 and September 27, 2024. The HHA failed to document the patient's weight in accordance with the plan of care for Patient #5. 5.) The clinical record for Patient #6 was reviewed for the period of March 25, 2024 through May 23, 2024. The plan of care effective March 25, 2024 for Patient #6 indicated physical therapy services frequency of one (1) time a week for one (1) week, two (2) times a week for two (2) weeks, and one (1) time a week for six (6) weeks. The missed visit form for Patient #6, dated April 05, 2024, indicated a physical therapy visit was not conducted on April 05, 2024, due to scheduling conflict with the Physical Therapist. The patient communication note dated April 10, 2024, indicated a fax was received from the facility where Patient #6 resides requesting discharge from the agency’s services per the Power of Attorney. The patient communication note in the clinical record dated April 10, 2024, indicated effective April 10, 2024, Patient #6 was discharged from the agency’s services. The HHA failed to provide physical therapy services in accordance with the plan of care for Patient #6. 6.) The clinical record for Patient #7 was reviewed for the period of February 28, 2024 through April 27, 2024. The plan of care for Patient #7 indicated physical therapy frequency two (2) times a week for four (4) weeks, one (1) time a week for two (2) weeks, and occupational therapy to evaluate and treat. The clinical record for Patient #7 did not contain documentation of a second physical therapy visit for the following week March 10, 2024, through March 16, 2024. The clinical record for Patient #7 did not contain documentation of any physical therapy visits for the following weeks: March 17, 2024, through March 23, 2024 March 24, 2024, through March 30, 2024 March 31, 2024, through April 05, 2024 April 07, 2024, through April 10, 2024. The clinical record for Patient #7 did not contain documentation of an occupational therapy evaluation or treatment. The patient communication note, dated April 10, 2024, indicated a fax was received from the facility where Patient #7 resides requesting immediate discharge from the agency’s services and Patient #7 was discharged effective April 10, 2024. The HHA failed to provide physical and occupational therapy services in accordance with the plan of care for Patient #7. 7.) The clinical record was reviewed for Patient #8 for the period of August 04, 2024 through October 02, 2024. The plan of care for Patient #8 effective August 04, 2024 revealed physical therapy frequency one (1) time a week for nine (9) weeks. The clinical record did not contain documentation of a physical therapy visit August 04, 2024, through August 10, 2024. The HHA failed to provide physical therapy services in accordance with the plan of care for Patient #8. 8.) The clinical record for Patient #9 was reviewed for the period of September 06, 2024 through November 04, 2024. The plan of care for Patient #9 indicated skilled nursing visit frequency two (2) times a week for eight (8) weeks. The plan of care for Patient #9 included the following order effective September 07, 2024: Clean wound below umbilicus with dermal wound cleanser, pack wound with Aquaculture AG (Aquacel AG is a wound dressing containing hydro fiber and ionic silver that forms a gel and removes harmful bacteria), cover with abdominal pads and tape to abdomen; patient to wear abdominal compression to hold wound items in place. The missed visit form dated September 12, 2024, revealed Patient #9 was unable to do the visit due to a scheduled doctor appointment and no notification provided to the MD. The following skilled nursing visits documented wound treatment provided: September 13, 2024, below umbilicus left and right side: gauze soaked, packed into wound, covered with ABD pad, secured with tape. September 17, 2024, below umbilicus left and right side: wet to dry dressing treatment and awaiting authorization for ointment. September 20, 2024, below umbilicus left and right side: wet to dry dressing, covered with ABD pad, secured with tape. September 24, 2024, below umbilicus left and right side: wet to dry dressing. Wound noted as having healthy tissues, no signs of infection, healing and improving. September 27, 2024, below umbilicus left and right side: wet to dry dressing. Wound on abdomen noted as healing and no signs of infection. October 01, 2024, below umbilicus left and right side: wet to dry dressing. Wounds on abdomen noted as healing and no signs of infection. October 04, 2024, wet to dry dressing below umbilicus (right side) and below umbilicus (left side), cleansed with Medi-honey to wound bed and covered with ABD pad. The clinical record for Patient#9 did not reveal the utilization of Aquacel Culture AC for wound, providing wound dressing as ordered, and did not contain documentation of physical therapy re-evaluation and treatment for Patient #9. The HHA failed to provide skilled nursing visits and wound care treatment in accordance with the plan of care for Patient #9. An interview conducted with Staff Member #4 on October 01, 2024 indicated the full-time physical therapist had changed to as needed status effective September 30, 2024, but the agency has a physical therapist assistant that comes from another agency to see patients. Staff Member #4 revealed the occupational therapist is no longer employed, was utilized as needed, but had stopped seeing patients within the timeframe of March or April 2024. Staff Member #4 indicated the agency no longer accepts referrals for occupational therapy due to not being able to meet needs of the patient. An interview conducted with Staff Member #1 on October 3, 2024, indicated all visits are made by staff per the patient’s plan of care. Staff Member #1 stated a physical therapy assistant from another office assists in completing visits in addition to the physical therapist. Staff Member#1 revealed Staff #11 resigned on September 27, 2024, and saw five (5) patients a day for three (3) days and all other days, Staff Member #11 would see seven (7) patients a day. Staff Member #1 stated she provides visits to patients in addition to Staff Members #5, #6 and #7. Staff Member #1 revealed the full time physical therapist (Staff Member #8, hired in January) changed to as needed status effective September 30, 2024, but would continue to see patients this week in addition to the PTA (Physical Therapy Assistant). An interview conducted with Staff Member #6 on October 3, 2024, indicated Staff Member #6 provides wound care to Patient #9. Staff Member #6 indicated wound care provided to Patient #9 is wet to dry dressing.

Quality assessment/performance improvement CFR(s): 484.65 Condition of participation: Quality assessment and performance improvement (QAPI). The HHA must develop, implement, evaluate, and maintain an effective, ongoing, HHA-wide, data-driven QAPI program. The HHA's governing body must ensure that the program reflects the complexity of its organization and services; involves all HHA services (including those services provided under contract or arrangement); focuses on indicators related to improved outcomes, including the use of emergent care services, hospital admissions and re-admissions; and takes actions that address the HHA's performance across the spectrum of care, including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of its QAPI program and be able to demonstrate its operation to CMS. This CONDITION is not met as evidenced by: Based on a review of the agency's policies and procedures, document review, and interviews it was determined the home health agency failed to implement, evaluate and maintain the Quality Assessment and Performance Program. On October 02, 2024, the Medical Facilities Inspector (MFI) reviewed the Quality Assessment and Performance Improvement Manual. Documentation indicated the Quality Assessment and Performance Improvement Committee meeting was held on October 30, 2023. The MFI reviewed the job description Licensed Practical Nurse (LPN) on October 01, 2024. The job description revealed participation in the Quality Assessment and Performance Improvement Committee as a requirement of position. The MFI reviewed the job description for the Administrator on October 01, 2024. The job description indicated implementing and monitoring the Quality Assessment and Performance Improvement Program to guarantee the delivery of high quality, personalized care as an essential job function and responsibility. Interviews conducted with Staff Member #3 and Staff Member #4 on September 30, 2024, indicated the agency does not have a specific policy relating to conducting a quarterly review of charts as this would be within the Quality Assessment and Performance Improvement (QAPI) program. An interview conducted with Staff Member #3 on October 2, 2024, indicated the last Quality Assurance Performance Committee Meeting was held on October 30, 2023, and no additional documentation could be located at the agency. Staff Member #3 indicated the agency has not implemented, evaluated and maintained the Quality Assessment and Performance Improvement Program since October 30, 2023.

Participate in the HHA's QAPI program; CFR(s): 484.75(b)(8) Participation in the HHA's QAPI program; and This ELEMENT is not met as evidenced by: Based on review of policy and procedures, document review and an interview, the agency failed to ensure all skilled professional staff provide input into and participate in the implementation of the Quality Assessment and Performance Improvement Program. Findings: On October 02, 2024, the Medical Facilities Inspector (MFI) reviewed the Quality Assessment and Performance Improvement Manual. Documentation indicated the Quality Assessment and Performance Improvement Committee meeting was held on October 30, 2023. The MFI reviewed the job description for the Licensed Practical Nurse (LPN) on October 01, 2024. The job description indicated participation in the Quality Assessment and Performance Improvement Committee as a requirement of the position. The MFI reviewed the job description for the Administrator on October 01, 2024. The job description indicated implementing and monitoring the Quality Assessment and Performance Improvement Program to guarantee the delivery of high quality, personalized care as an essential job function and responsibility An interview conducted with Staff Member #3 on October 2, 2024, indicated the last Quality Assessment and Performance Improvement Committee Meeting was held on October 30, 2023, and no additional documentation could be located at the agency. Staff Member #3 indicated the agency has not implemented, evaluated and maintained the Quality Assessment and Performance Improvement Program since October 30, 2023. The agency failed to ensure all skilled professional staff provide input into and participate in the implementation of the Quality Assessment and Performance Improvement Program.

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on policy and procedure review, and document review and interviews, it was determined the home health agency failed to follow the agency's policies and procedures by not maintaining an after hours call log, and providing orientation and documentation of skills competency for six (6) out eleven (11) staff members (Personnel Records for Staff Member #1, #5, #6, #7, #11, #12). Findings: The Medical Facilities Inspector (MFI) reviewed the agency on-call log on September 30, 2024. The on-call log did not contain any entries after March 02, 2024. On October 02, 2024, the MFI reviewed the on-call print out provided by Staff Member #3. The printout from the on-call answering service indicated after hours calls received from January 8, 2024, through September 29, 2024. The agency’s On-Call policy (Virginia Main ACHC (Accreditation Commission for Health Care); Medicare Polices v2, Effective November 29, 2019) was reviewed in the agency on September 30, 2024. Page 145 #3, of the On-Call indicates the agency will monitor on-call activity. An on-call log will be maintained. This is done to ensure tracking, and monitoring, of after-hours activity, to provide consistent case management to patients/clients with an on-call system, and to determine handling of after-hour needs, relating to patient care. Page 146 #8 of the On-Call policy indicates on call logs will be reviewed by the Agency Clinical Manager or designee, and the Quality Assessment and Performance Improvement Committee will be considered as part of the agency’s QAPI process. On September 30, 2024, an interview was conducted with Staff Member #1 who indicated she was appointed as interim administrator effective September 13, 2024, due to the former administrator resigning without a notice. Staff Member #1 indicated she had been employed with the agency since May 30, 2024. Staff Member #1 revealed the agency does not keep an on-call log. The HHA failed to maintain an after hours call log. The agency’s Competency Assessment Program policy (Virginia Main ACHC (Accreditation Commission for Health Care); Medicare Polices v2, Effective November 29, 2019) was reviewed in the agency on October 3, 2024. The Statement of Standard (HH4-6A.01) on page 298 indicated competency assessments are conducted initially during orientation, prior to providing a new task and annually thereafter. Responsibility of the Agency on page 298 #2 of the Competency Assessment Program indicated all competency assessments and training are documented. Policies on page 298 #1 of the Competency Assessment Program indicated the minimum education and training, licensure, certification, experience, and the minimum competencies are required for each care/service offered. The MFI reviewed eleven (11) personnel files on October 1, 2024. Of the eleven (11) personnel records reviewed, eight (8) provided skilled nursing services. Six (6) of the eleven (11) personnel records reviewed did not contain the following required documentation: The personnel record for Staff Member #1(Registered Nurse) hired on May 30, 2024, did not contain a competency skills checklist and documentation of orientation. The personnel record for Staff Member #5 (Licensed Practical Nurse) hired on August 28, 2024, did not contain a competency skills checklist, and documentation of orientation. The personnel record for Staff Member #6 (Licensed Practical Nurse), hired on July 29, 2024, did not contain a competency skills checklist and documentation of orientation. The personnel record for Staff Member #7 (Licensed Practical Nurse) hired on August 12, 2024, did not contain a competency skills checklist and documentation of orientation. The personnel record for Staff Member #11, (Licensed Practical Nurse) hired on April 12, 2024, did not contain a competency skills checklist and documentation of orientation. The personnel record for Staff Member #12 (Registered Nurse) hired on September 03, 2024, did not contain a nursing license, competency skills checklist, and documentation of orientation. The HHA failed to provide orientation and documentation of skills competency for Staff Members #1, #5, #6, #7, #11, #12. On October 02, 2024, the MFI interviewed Staff Member #4 who indicated the staff member responsible for orientation and competency skills checklists for newly hired staff resigned without notice and Staff Member #1 was appointed as the interim administrator effective September 13, 2024.