Every finding on record at Southside Community Hospital, Inc.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency October 18-20, 2021 and October 25-26, 2021 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. 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.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency October 18-20, 2021 and October 25-26, 2021 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency reported 704 unduplicated admissions during the last 12 months. In conjunction with the survey, the clinical records of (17) patients, three (3) personnel files, an agency admission packet, the complaint log, the CLIA (Certified Laboratory Improvement Amendments) waiver were reviewed. Seven (7) home visits 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.

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 review of clinical records and staff interviews, it was determined the agency staff failed to ensure home health services were provided according to the patient's individualized plan of care for one (1) of (17) patients whose clinical records were reviewed in the survey process. Specifically, agency staff failed to document the required assessment of a patient weights and education of the patient and or caregiver in the importance of weighing at predetermined times. (Clinical record # 4). The findings: Seventeen (17) clinical records were reviewed with read only access on 10/19/2021 and 10/25/2021 with the following findings: 1. The clinical record for patient #4 was reviewed for the certification period of 9/10/2021 to 11/08/2021. The patient's plan of care contained orders as follows: Skilled Nurse every visit assess patient's weight record and trend; notify cardiology for a weight gain or loss of 3 lbs in one to two days or 5 lbs in week. For weight loss, assess for orthostatic hypotension prior to calling MD (Medical Doctor). On 10/25/2021 at 3:36 PM this MFI (Medical Facilities Inspector) called the primary Skilled Nurse (staff member #11) who had visited the patient 16 times out of 20 visits and asked where are the weight records or trends. The Skilled Nurse stated, no the patient has not weighed themselves and is staying at their parent's house and no scale is there. The MFI stated, have you notified the physician of no weights being obtained and the Skilled Nurse stated, I guess I should have charted the patient's weights was not being done by patient. The clinical record failed to contain documentation that the nurse assessed the patient's weight as ordered in the plan of care. In addition, the patient's plan of care contained orders to educate/instruct patient/caregiver using teach-back method of weighing each morning post voiding and prior to eating; signs of exacerbation of weight gain of 3 lbs in 1-2 days and/or 5 lbs in one week, increased peripheral edema, abdominal, sacral and scrotal edema, dyspnea, orthopnea & paroxysmal nocturnal dyspnea and signs and symptoms of dehydration: dizziness, lightheadedness fatigue, and/or cramping associated with a weight loss of 3 lbs in 1-2 days or 5 lbs in one week. The clinical record failed to contain documentation that the nurse educated the patient/caregiver on the above related topics of weighing that were listed in the plan of care orders. This was confirmed by the Clinical Manager on 10/26/2021 at 11:00 AM. The above noted findings were reviewed and acknowledged with the Director and the Clinical Manager on 10/26/2021 at 12:30 PM