Every finding on record at Southeastern Home Health Care, LLC

An unannounced Home Health Agency recertification survey was conducted on August 2-4, 2021 by two (2) Medical Facilities Inspectors 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 recertification survey was conducted on August 2-4, 2021 by two (2) Medical Facilities Inspectors from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 1048 unduplicated admissions for the past twelve months. The unduplicated census includes one (1) branch that was visited in conjunction with the survey, which is located at: Yorktown-2405 Ft. Eustis Blvd-Suite 238, Yorktown 23692 In conjunction with the survey, seventeen (17) clinical records, ten (10) personnel files, an admission packet, complaint log, emergency preparedness, CLIA (Clinical Laboratory Improvement Amendments) and the organization chart were reviewed. Seven (7) home visits and staff interviews were conducted. The agency was found not to be in compliance with the federal requirements of 42 CFR 484, Conditions of Participation for Home Health Agencies. 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 interviews and document review, it was determined the agency failed to ensure that patients were informed about and consented to the frequency of proposed visits in advance of starting care in seventeen (17) of seventeen (17) clinical records reviewed in the survey sample (clinical record #'s 1-17). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 2-4, 2021. The consent for care form located in each patient's record failed to contain documentation of the disciplines and the frequency of visits to be provided in any of the seventeen clinical records reviewed. No additional documentation in the clinical records contained this information. During home visits conducted on August 2-3, 2021, the folders left in each patient's home by agency staff were reviewed. There was no indication in the folders of the disciplines or the frequency of services to be provided. When interviewed, the patient and/or caregiver stated they knew when someone was coming because they would call. An interview on August 4, 2021 at approximately 2:30 PM with the Administrator and VP revealed the agency had a prior document with that information on it but it was no longer used. The findings were reviewed with the Administrator and Vice President again during the exit conference on 8/04/2021.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on clinical record review, it was determined the agency failed to ensure that the initial assessment for each patient was completed within 48 hours of the referral for one (1) of seventeen (17) clinical records reviewed in the survey sample (clinical record #1). The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 2-4, 2021. Clinical record #1 was reviewed for the certification period of 6/08/2021-8/06/2021. The clinical record revealed a referral date of 5/30/2021 with a hospital discharge date of 6/03/2021. The patient was not opened to home health services until 6/08/2021. The clinical record failed to contain any documentation to support the delay in admission. A interview was conducted with the Clinical Quality Specialist (staff #10) on 8/03/2021 at 12:30 PM. Staff #10 attempted to located the information but was also unable to locate documentation related to the reason for the delay in providing services to the patient. The finding was reviewed with the Administrator and Vice President during the exit conference on 8/04/2021.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on an interview and a review of clinical records it was determined the agency's staff failed to ensure a plan of care contained specific information required on the plan of care for one (1) of one (1) clinical records for patients receiving tube feedings and were reviewed in the survey sample (clinical record #3 ). Specifically, the plan of care failed to contain specific orders for tube feedings and needed supplies. The findings were: The electronic clinical records were reviewed both onsite and offsite in read only mode from August 2-4, 2021. The clinical record for patient #3 was reviewed for the certification period of 7/04/2021 to 9/01/2021. A review of clinical notes revealed the patient had a PEG tube (percutaneous endoscopic gastrostomy) used to provide nutrition directly through the stomach. The plan of care failed to contain orders for the PEG tube to include if the feedings were done on a pump or by gravity, the amount to be given, any care that was needed for the site and the supplies needed. An interview was conducted with staff member #10 on August 3, 2021 beginning at 2 PM. Staff member #10 also stated she was unable to locate any specific orders related to the PEG tube, feedings or care. The findings were reviewed with the Administrator and Vice President during the exit conference on 8/04/2021.

Ensure clinical manager is available CFR(s): 484.105(b)(1)(iii) (iii) Ensure that a clinical manager as described in paragraph (c) of this section is available during all operating hours; This ELEMENT is not met as evidenced by: Based on an interview it was determined the agency failed to ensure a Clinical manager was available during all operating hours. The findings were: An interview conducted with the administrator during the entrance conference on 8/02/2021 at 9 AM revealed the agency did not have a clinical manager and the previous manager had resigned in April 2021. The administrator stated they had been recruiting for the position but had not found a suitable candidate. The findings were reviewed with the Administrator and Vice President during the exit conference on 8/04/2021.

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 five (5) business days of discharge for two (2) of five (5) discharged patients in the survey sample (Clinical records #15 and #17). The findings were: A review of the five discharged clinical records was conducted on August 3-4, 2021. The survey team was unable to tell from the clinical records when the discharge summary was sent to the physician. An interview was conducted with the Vice President (VP) for assistance on 8/04/2021. The VP had office staff assist and provided the information with the following findings. The clinical record for patient #15 was reviewed for the certification period of 5/15/2021 to 7/13/2021. The record revealed a discharge date of 7/09/2021. The discharge summary was not sent to the physician until 7/22/2021. The clinical record for patient #17 was reviewed for the certification period of 1/17/2021 to 3/17/2021. The record revealed a discharge date of 3/09/2021. The discharge summary was not sent to the physician until 5/13/2021. The findings were reviewed with the Administrator and Vice President during the exit conference on 8/04/2021.