Every finding on record at Total Home Health Care, Inc.

An announced Medicare/Medicaid Home Health Recertification survey was conducted 02/03-12/2021. Part of the survey was conducted on site and the remainder as an offsite virtual review via the telephone and email due to the COVID-19 Public Health Emergency declared by the Governor. In conjunction with this survey the agency's emergency preparedness plan was reviewed. The agency was found not to be in compliance with 42 CFR 484.113 Conditions of Participation Emergency Preparedness for Home Health Agencies effective 11/15/2017.

EP Program Patient Population CFR(s): 484.102(a)(3) §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: ["Persons at risk" does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This STANDARD is not met as evidenced by: Based on staff interview and document review it was determined the agency failed to ensure their emergency preparedness plan included a description of the agency's clients to include, but not limited to, persons at risk, and the type of services the agency has the ability to provide in an emergency. Findings: The agency's emergency preparedness plan was reviewed on February 11, 2021. The emergency plan failed to include a description of the agency's clients to include, but not limited to, persons at risk, and the type of services the agency has the ability to provide in an emergency. The lack of the above noted information was discussed with the administrator (staff #1) prior to and during the exit conference on February 12, 2021.

Policies/Procedures for Medical Documentation CFR(s): 484.102(b)(4) §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This STANDARD is not met as evidenced by: Based on staff interview and document review it was determined the agency failed to ensure the policy and procedure section of their EPP failed to contain a description of their medical documentation that preserves patient information, protects confidentially of patient information and secures and maintains availability of records. Findings The agency's emergency preparedness plan (EPP) was reviewed on November 19, 2020. The policy and procedure section failed to contain a description of their medical documentation that preserves patient information, protects confidentially of patient information and secures and maintains availability of records. The lack of the above noted information from the policy and procedure section was reviewed with the Administrator prior to and during the exit conference on 02/12/2021.

An announced Medicare/Medicaid Home Health recertification survey was conducted at the above noted facility on February 3-12, 2021 by one Medical Facilities Inspector (MFI) from the Office of Licensure and Certification (OLC). Part of the survey was conducted on site and the remainder as an offsite virtual review via the telephone and email due to the COVID-19 Public Health Emergency declared by the Governor. The agency identified (431) unduplicated admissions in the last twelve (12) months. In addition, the agency has branches located at the following addresses: MSA Wise, 413 E. Main Street, P. O. Box 3699, Wise, VA 24293, and MSA Abington, 206 Abington Place, Abington, Va. 24211. Each branch was toured by the MFI. Patient visits were attempted at each of the branch locations. The records of ten (10) patients, 15 employees, the complaint log, the agency's Admission Packet, and various selected Policies and Procedures were reviewed. The facility failed to be in compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on staff interview and document review it was determined the agency failed to ensure the Administrator's name was included with the contact information for complaints in order for patients to lodge a complaint. Findings: The agency's admission packet given to patient's at the time of admission was reviewed in the agency on 02/04/2021. The complaint section of the packet on page 34 failed to contain the name of the agency Administrator. The lack of the agency's Administrator's name with their complaint information was discussed with the Administrator prior to the exit conference.

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 staff interview and document review it was determined the agency failed to ensure each patient was informed prior to services beginning of one or more of the following: disciplines that will furnish the care, frequency of visits for each discipline, and the financial cost and responsibility of these services for five (5) of ten (10) patient records whose records were reviewed in the survey sample.Patient Records: #1, 3, 4, 5, and 8. Findings: Ten (10) patient records were reviewed on 02/08-10/2021 with the following findings: 1. Patient record #1 with a start of care date of 08/18/2020 was reviewed for the time frame of 12/15/2021-01/23/2021. The patient's informed consent (a consent signed at the time of admission) failed to contain a frequency of prposed visits. 2. Patient record #3 with a start of care date of 12/30/2020 was reviewed for the time frame of 12/30/2020 to 02/08/2021. The patient's informed consent failed to contain documentation of the frequency of occupational therapy visits and whether the patient would have to pay a co pay per visit 3. Patient record #4 with a start of care date of 01/06/2021 was reviewed for the time frame of 01/06/2021 to 02/15/2021. The patient's informed consent failed to contain documentation regarding the frequency of skilled nursing services. 4. Patient record #5 with a start of care date of 06/08/2020 was reviewed for the time frame of 10/06/2020 to 10/26/2020. The patient's informed consent failed to contain documentation regarding the frequency of proposed skilled nursing services. 5. Patient record #8 with a start of care date of 11/12/2020 was reviewed for the time frame of 11/16/2020 to 01/07/2021. The patient's informed consent failed to contain documentation of whether the patient would have to pay a co pay per visit. The lack of completing all required blanks on the above noted informed consents was reviewed with the administrator on 02/12/2021.

State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This ELEMENT is not met as evidenced by: Based on staff interview and document review it was determined the agency's information in their admission booklet regarding the agency's grievance process failed to contain the required information. The following information was missing from the booklet: state toll free home health telephone hot line, ithe agency's contact information including hours of operation, and that its purpose is to receive complaints or questions about local HHAs (home health agencies). Findings: The agency's admission booklet given to the patient at the time of admission to home health was reviewed in the agency on 02/04/ 2021. At the top of page 5 the following was documented: "Rights and Responsibilities" and at the bottom of page 5 the following was documented, "Be advised of the availability, hours of operation and purpose of the State Home Health Agency Hotline. The purpose of this hot-line is to receive complaints and questions regarding local home health agencies." The admission packet failed to contain the state toll free home health hot line number, its contact information and its hours of operation. At the top of page 34 of the admission booklet titled " Patient Concerns and Grievance Process" a diagram is displayed regarding how a complaint is handled once received by the agency. The first box reads, " Call your Home Health Agency. "Monday -Friday 8 am-PM." The name and telephone number of the agency Administrator failed to appear on this page. The lack of the above noted information in the agency's admission booklet was reviewed with the Administrator prior to and during the exit on 02/12/21.