Every finding on record at Tender Loving Care Health Care Services of West Virginia, LLC

An emergency preparedness survey was conducted at Adoration Home Health of Morgantown WV and the agency's Anmoore and Wheeling branch offices from April 27, 2026 through April 29, 2026. It was determined the facility is in compliance with the Emergency Preparedness Conditions of Participation for Home Health agencies.

A recertification survey was conducted at Adoration Home Health of Morgantown, WV and the agencies' branch offices in Anmoore and Wheeling from April 27, 2026 through April 29, 2026. It was determined the facility was not in compliance with the requirements of 42 CFR, Part 484 - The Medicare Conditions of Participation for Home Health Agencies.

Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This STANDARD is not met as evidenced by: Based on document review, observation and staff interview it was determined the agency failed to ensure the Information Security Department provided the State surveyors with access to the Electronic Health Records (EHR) in a timely fashion as requested. This failure has the potential to negatively impact all patient care by impeding the survey process by unnecessarily delaying access to medical records. A policy titled "Clinical Records", dated 10/24/25 was reviewed and states in part, "POLICY: The Agency must maintain an organized clinical record containing past and current information for each patient accepted by the Agency and receiving home health services... PROCEDURE: 13. The patient's record, whether hard copy or electronic form, will be made readily available upon request by an appropriate authority." ... Upon entrance to the Morgantown office on 4/27/26 at approximately 10:30 a.m., it was observed the agency uses an electronic charting system for all treatment modalities. To safeguard access to the Electronic Health Record (EHR), each person is issued their own authentic username and password. The state surveyors immediately requested access to the EHR but did not receive access until 12:00 p.m., for closed records only. The state surveyors were told that access to all records would require using two (2) different computers and systems. The surveyors could not access active patient records on 4/27/26. Surveyors were told that the agency would send for the delivery of the second computers and the surveyors would have them the morning of 4/28/26. Upon entering the Morgantown office on 4/28/26 at 8:15 a.m., the second computer was not available. At 9:40 a.m. the surveyor received one (1) computer and username and password. At 10:35 a.m., the surveyor was made aware that one (1) of the branch location records wasn't available on the computer. At 11:21 a.m., the surveyor received access to all locations. At the Morgantown office on 4/29/26, the surveyor attempted to access the medical records at 8:45 a.m. with the username and password that was given. The surveyor was unable to access the records. The agency administrator stated that there was some issue with the authenticator system. The surveyors never regained access to the patient records. Upon entering the Wheeling branch office on 04/28/26 at 8:30 a.m., the surveyor was unable to get access to the computer until 12:30 p.m. Staff 2 stated they were having system issues. The password for the home care/home base was not working. At the Wheeling office on Wednesday 4/29/26, the surveyor attempted to access the records. The surveyor was unable to access the records as the authenticator option for the home health home base was unavailable. The surveyor had no access until 12:29 p.m. An interview was conducted with staff 1 on 4/29/26 at approximately 11: 27 a.m. Staff 1 concurred with the above findings.

An emergency preparedness survey was conducted at Amedisys Home Health Care from 05/10/21 to 05/12/21 as part of a recertification survey. One (1) standard level deficiency was cited at E 030.

Names and Contact Information CFR(s): 484.102(c)(1) §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on document review and staff interview it was determined the facility failed to maintain an emergency preparedness communication plan with current and accurate staff contact information for the facility call tree. This failure was identified in two (2) out of three (3) locations (parent facility and branch #2). This failure places all patients at risk for harm due to failure to notify direct care staff in order to meet patient needs in emergencies. Findings include: 1. A review of the parent facility's "Emergency Preparedness Plan" (EPP) revealed an "EPP Staff Notification Tree," dated 05/13/20, which listed Director of Operations #1, who was no longer employed at the facility, as the second contact in the phone tree. The call tree, including names and phone numbers of staff, was outdated and not backed up to ensure availability during an emergency. 2. A review of the branch #2's EPP revealed an "EPP Staff Notification Tree," which listed Director of Operations #1, who was no longer employed at the facility, as the second contact in the phone tree. The call tree, including names and phone numbers of staff, was outdated and not backed up to ensure availability during an emergency. 3. A review of facility policy "Emergency Management Planning," dated 03/2021, states in part: "This plan was developed as a means to continue care, treatment, and services for the active patients ... in a manner that is as seamless as possible before, during and after a disaster, systems failure and other emergencies/events. To provide the home care staff with guidelines so that disruption of patient care is kept to a minimum and that coordination of care may be continued for patients served in our area ... Staff members, as appropriate to the extent and nature of the emergency, will be notified by Staff Notification Tree. In the event of an emergency or activation of the emergency management plan, all staff will be contacted utilizing the Staff Notification Tree. Each appointed staff member will notify the staff below them on the calling list." 4. An interview was conducted with the Director of Operations Branch #2 on 5/10/21 at 10:45 a.m. She revealed the emergency contact call tree for staff was not current and was only located in one (1) place (the computer system). 5. An interview was conducted on 05/11/21 at approximately 12:07 p.m. with Clinical Manager #1 at the parent facility. When asked who is responsible for the EPP, she stated in part, "I am since I am here." When asked when the last administrator left, she verbalized it was in February 2021. When notified the call tree in the EPP was not updated with the current administrator, she stated in part, "Well, since I am the only one here all the staff know to call me. I will get the tree updated."

A recertification survey was conducted at Amedisys Home Health Care from 05/10/21 through 05/12/21. The agency provides skilled nursing, physical therapy, occupational therapy, speech therapy, medical social work and home health aide services to Barbour, Brooke, Doddridge, Grant, Harrison, Lewis, Marion, Marshall, Monongalia, Ohio, Preston, Taylor, Tyler, Tucker, Wetzel and Upshur counties. The agency provides oversight from the parent office in Morgantown, West Virginia and operates two (2) branches located in Anmoore and Wheeling, West Virginia. At the time of the survey, the agency had a combined active census of four hundred forty-three (443) patients for the parent and branch offices. The combined unduplicated admissions for the past twelve (12) months were one thousand eight hundred and eighty-one (1881). A total of eighteen (18) clinical record reviews were reviewed and six (6) home visits were observed with skilled nurses, physical therapy, occupational therapy and speech therapy. One (1) Condition was cited at G 510 with a related standard level deficiency cited at G 530. As a result of the cited Condition level deficiency, this agency will not be permitted to complete home health aide training or competency evaluations for two (2) years as per regulation 42 CFR 484.80(f)(3). A. Noncompliance: An Immediate Jeopardy (IJ) to a Comprehensive Assessment of Patients (Patients strengths, goals and care preferences) was called on 05/10/21 at 11:19 a.m. because the facility failed to ensure nursing fully assessed patients' advance directives and obtain the patients' care preference of "Do Not Resuscitate" (DNR)/"Do Not Intubate" (DNI) and notify the physician to obtain orders in accordance with the facility's policies and procedures. B. Harm or Potential Harm: The patient could have physical and emotional injuries sustained from receiving cardiopulmonary resuscitation. C. Immediacy: The facility needs to take action to ensure patients' advance directives for patient care are followed and to ensure staff follow-up during future visits to obtain copies of patients' advance directives. D. A remedial plan of correction was received and sent to the State Agency Program Manager. The plan was accepted by the surveyor and the facility abated the IJ on 05/12/21 at 2:22 p.m. by immediately: conducting re-education of staff to follow Advance Directives and DNR/DNI facility policies; obtain Advance Directives information when new patient referrals are received; ask all patients upon admission about Advance Directives, their code status preferences, continue efforts to obtain a copy of their Advance Directives to file in patients' charts and notify the physician if the patient wishes to not have a full code status. An alert will be added to the point of care visit to notify staff to attempt to obtain a copy of the patients' Advance Directives. Advance Directive questions will be added to every assessment visit in the electronic record. All current patients will have their Advance Directives and patient wishes for code status re-assessed at their next visit.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on record review, document review and staff interview it was determined the facility failed to ensure the agency provided a patient-specific comprehensive assessment at the time of the initial and comprehensive visit in one (1) out of eighteen (18) clinical records reviewed (patient #13). This failure has the potential to place all patients at risk for their advance directives and care preferences of code status to not be followed (See Tag G 530). A. Noncompliance: An Immediate Jeopardy (IJ) to a Comprehensive Assessment of Patients (Patients strengths, goals and care preferences) was called on 05/10/21 at 11:19 a.m. because the facility failed to ensure nursing fully assessed patients' Advance Directives and obtain the patients' care preference of "Do Not Resuscitate" (DNR)/"Do Not Intubate" (DNI) and notify the physician to obtain orders in accordance with the facility's policies and procedures. B. Harm or Potential Harm: The patient could have physical and emotional injuries sustained from receiving cardiopulmonary resuscitation. C. Immediacy: The facility needs to take action to ensure patients' Advance Directives for patient care are followed and to ensure staff follow-up during future visits to obtain copies of patients' Advance Directives. D. A remedial plan of correction was received and sent to the State Agency Program Manager. The plan was accepted by the surveyor and the facility abated the IJ on 05/12/21 at 2:22 p.m. by immediately: conducting re-education of staff to follow Advance Directives and DNR/DNI facility policies; obtain Advance Directives information when new patient referrals are received; ask all patients upon admission about Advance Directives, their code status preferences, continue efforts to obtain a copy of their Advance Directives to file in their chart and notify the physician if the patient wishes to not have a full code status. An alert will be added to the point of care visit to notify staff to attempt to obtain a copy of the patients' Advance Directives. Advance Directive questions will be added to every assessment visit in the electronic record. All current patients will have their Advance Directives and patient wishes for code status re-assessed at their next visit.

Strengths, goals, and care preferences CFR(s): 484.55(c)(2) The patient's strengths, goals, and care preferences, including information that may be used to demonstrate the patient's progress toward achievement of the goals identified by the patient and the measurable outcomes identified by the HHA; This ELEMENT is not met as evidenced by: Based on record review, document review and staff interview it was determined the facility failed to ensure nursing assessed and documented a patient's care preferences for Advance Directives and notify the physician of the patient's wish for Do Not Resuscitate (DNR) status. This failure was identified in one (1) out of eighteen (18) clinical record reviews (patient #13). This failure has the potential to place all patients at risk for their Advance Directives and care preferences of code status to not be followed. Findings include: 1. A review of the clinical record for patient #13 revealed the patient is a ninety-four (94) year old male with a diagnosis of dementia. Review of the patient's initial comprehensive and OASIS assessments, dated 10/13/20, revealed he had an advanced care plan which included a living will and a durable Power of Attorney. The record did not include a copy of the patient's Living Will, no documentation stating the patient was a DNR status, no documentation of a discussion about the living will for his preferences, or any notification to the physician of his preferences. The patient's consent, signed 10/13/20, stated in part: "I have executed a Living Will, I have [Indicates Power of Attorney]. The individual that I have granted power of Attorney for my health care is: [patient's wife's name] ... I have not given [the facility] a copy of the document(s) as applicable." A review of the plans of care for certification periods 10/13/20 through 12/11/20, 12/12/20 through 02/09/21, 02/10/21 through 04/10/21 and 04/11/21 through 06/09/21, stated in part: "Advance Directives: None." 2. A review of facility policy "Advance Directives," revised 11/2019, states in part: "The agency will document attempts to obtain a copy of the document for the patient's clinical record. If the patient has Advance Directives but does not provide the agency with a copy of the document, the agency may record the patient's wishes on the medical record but cannot be held responsible for the implementation of the specifics of the Advance Directives ... The agency has a process that keeps staff who are directly involved in patient care knowledgeable as to the status and existence of Advance Directives or Durable Power of Attorney for Health Care. Information relating to advance directives is placed in the plan of care ... The patient's physician will be notified of the existence of Advance Directives. A notation will be made in the clinical record." 3. A review of facility policy "Do not Resuscitate (DNR)/Do not Intubate (DNI)," revised 11/2019, states in part: "Purpose: The agency shall provide patients the right to request limitations in the scope of care rendered, including "Do Not Resuscitate" (DNR) and/or "Do Not Intubate" (DNI). To provide guidance for "Do Not Resuscitate"/"Do Not Intubate" physician orders. To ensure state specific requirements for DNR/DNI orders are implemented as mandated by regulations ... If the patient does not have a DNR order and wishes to initiate one, the nurse will contact the patient's physician and the clinical manager to communicate the patient's wishes ... Written advanced directives (living will and/or durable power of attorney for health care) shall not substitute for obtaining the consent of the patient or legal representative the entry of a DNR order. Nor does such document substitute for a DNR order." 4. An interview was conducted on 05/11/21 at 8:55 a.m. with Registered Nurse #2 prior to patient #13's home visit. When asked if the patient had a living will, she stated in part, "He is a full code." When questioned if he had a living will, she stated in part, "I don't know. I haven't seen one." 5. An interview was conducted on 05/11/21 at approximately 10:30 a.m. with the Director of Operations #2. She concurred there was no discussions or follow-up with the patient about obtaining the patient's living will. Her expectation was follow-up attempts to obtain the Living Will and Medical Power of Attorney will be documented on visits, following the initial visit, frequently until obtained. 6. A phone interview was conducted on 05/12/21 at approximately 8:50 a.m. with patient #13's surrogate. When asked if the patient has a Living Will and what his wishes are, she stated in part, "Yes. I couldn't tell you all of it, but he does not want resuscitated." 7. An interview was conducted on 05/12/21 at approximately 11:10 a.m. with the Area Vice President of Operations. When notified patient #13 had a Living Will and his preferences were not documented in the chart and the physician was not notified of the patient's preferences, she concurred and stated, "We dropped the ball on this one."