Every finding on record at Southwest VA Home Health Care

An unannounced Medicare/Medicaid home health recertification survey was conducted at the above noted agency 07/25/2022 to 07/27/2022 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 07/25/2022 to 07/27/2022 by one (1) Medical Facilities Inspector from the Virginia Department of Health, Office of Licensure and Certification. The agency reported 187 unduplicated admissions during the last 12 months. In conjunction with the survey, the following were reviewed: seven (7) clinical records, four (4) personnel files, COVID-19 vaccination requirement, agency admission packet, complaint log, organizational chart, and CLIA (Certified Laboratory Improvement Amendments) waiver. Three (3) home visits and multiple staff interviews were conducted. The facility was found not to be in compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of 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 clinical record review and staff interview it was determined the agency failed to ensure patients were informed about and consented to the frequency of proposed visits in advance of starting care for one (1) of seven (7) clinical records in the survey sample (Clinical record # 1). Findings: Seven (7) clinical records were reviewed in the agency on 07/26/2022 and 07/27/2022 with the following findings: 1. The "Client Services" form signed at the time of admission and prior to services being provided for patient #1 with a start of care date of 07/05/2022 failed to contain documentation of the frequency of Skilled Nursing and Physical Therapy services the patient would be receiving. The frequency section of the form was not completed by the clinician. In addition, the plan of care for 07/05/2022 to 09/02/2022 also contained an incomplete statement which reads as follows, "Patient or patient caregiver has been notified of the frequency by _______________ on date _______________". The above noted findings were acknowledged by the Administrator and Clinical Manager prior to and during the exit conference conducted in the agency on 07/27/2022.

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 the initial assessment for each patient was completed within 48 hours of the referral/inpatient discharge for one (1) of seven (7) clinical records in the survey sample (Clinical record #1). Findings: Seven (7) clinical records with reviewed in the agency on 07/26/2022 and 07/27/2022 with the following findings: Clinical record #1 was reviewed for the certification period of 07/05/2022-09/02/2022. Per the Start of Care (SOC) Outcome and Assessment Information Set (OASIS) the initial assessment was conducted on 07/05/2022. The patient's referral and inpatient discharge date was reported as 06/29/2022 and no specific SOC date was ordered by the physician per the SOC OASIS. The patient failed to be admitted within 48 hours of referral/inpatient discharge and the clinical record failed to contain documentation the physician was notified and approved of delay within the required 48 hour timeframe. The above noted findings were acknowledged prior to and during the exit conference conducted in the agency on 07/27/2022.

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 clinical record review and staff interview, it was determined the agency failed to ensure that each patient's individualized plan of care included all required elements for seven (7) of seven (7) clinical records in the survey sample (Clinical Records #1, #2, #3, #4, #5, #6, and #7) Findings: Seven (7) clinical records were reviewed in the agency on 07/26/2022 and 07/27/2022 with the following findings: 1. Clinical record #1 was reviewed for the certification period 07/05/2022 to 09/02/2022. The plan of care (POC) for the above noted timeframe failed to contain 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. In addition, the plan of care also contained an incomplete statement which reads as follows, "Patient or patient caregiver has been notified of the frequency by _______________ on date _______________". Also, the Advanced Directive section of the plan of care was not completed. 2. Clinical record #2 was reviewed for the certification period 06/22/2022 to 08/20/2022. The plan of care (POC) for the above noted timeframe failed to contain 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. In addition, the plan of care also contained an incomplete statement which reads as follows, "Patient or patient caregiver has been notified of the frequency by _______________ on date _______________". 3. Clinical record #3 was reviewed for the certification period 04/29/2022 to 06/27/2022. The plan of care (POC) for the above noted timeframe failed to contain 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. 4. Clinical record #4 was reviewed for the certification period 05/03/2022 to 07/01/2022. The plan of care (POC) for the above noted timeframe failed to contain 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. Also, the Advanced Directive section of the plan of care was not completed. In addition, the medication section of the plan of care contained Albuterol 90 micrograms every six (6) hours as needed (PRN). The POC failed to contain the reason which would necessitate the use of the PRN medication. 5. Clinical record #5 was reviewed for the certification period 07/10/2022 to 09/07/2022. The plan of care (POC) for the above noted timeframe failed to contain 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. Also, the clinical record contained documentation the patient had a Do Not Resuscitate (DNR) advanced directive. The advanced directive section of the plan of care was blank and failed to contain documentation of patient's DNR which was signed and dated 03/12/2022. In addition, the medication section of the plan of care contained Tylenol tablet 500 milligrams one (1) tab at bed time PRN (As needed). The POC failed to contain the reason which would necessitate the use of the PRN medication. 6. Clinical record #6 was reviewed for the certification period 06/30/2022 to 08/28/2022. The plan of care (POC) for the above noted timeframe failed to contain 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. Also, the Advanced Directive section of the plan of care was not completed. In addition, the medication section of the plan of care contained Proair 90 micrograms four times a day as needed (PRN). The POC failed to contain the reason which would necessitate the use of the PRN medication. 7. Clinical record #7 was reviewed for the certification period 06/13/2022 to 08/11/2022. The plan of care (POC) for the above noted timeframe failed to contain 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. Also, the Advanced Directive section of the plan of care was not completed. During an interview conducted in the agency during the clinical record reviews the Clinical Manager acknowledged the above noted findings and stated the plans of care should not contain any blank statements or sections and the nurses have been informed repeatedly they must document the reason for PRN (as needed) medications. The above noted findings were also acknowledged again by the Administrator and Clinical Manager during the exit conference conducted in the agency on 07/27/2022.