Every finding on record at Virginia In-Home Partner- V LLC

An unannounced Home Health Agency Medicare Medicaid recertification survey was conducted May 24-26, 2022 by one (1) Medical Facilities Inspector 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 Medicare Medicaid Home Health Agency recertification survey was conducted May 24-26, 2022 at the above captioned agency by one (1) Medical Facilities Inspector from The Office of Licensure and Certification, Virginia Department of Health. The agency reported 1090 unduplicated admissions in the last twelve (12) months with an active census of 80 patients. The following were completed/reviewed in conjunction with the survey: Seven (7) home visits, seventeen (17) clinical records, six (6) personnel files, review of selected policies and procedures, the agency's complaint log, emergency preparedness plan, and staff Covid vaccination records. Interviews were also conducted. Deficiencies were identified and cited in this report The agency was found to be out of compliance with 42 CFR 484, Conditions of Participation for Home Health Agencies (HHAs).

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on staff interview and review of clinical records it was determined the agency's staff failed to follow physician’s orders for two (2) of seventeen (17) clinical records reviewed in the survey sample (clinical records #3 and 9). The findings were: The electronic clinical records were reviewed in read only mode on May 24-26, 2022. 1. Clinical record #3 was reviewed for the certification period of 2/22/2022 through 4/22/2022. The patient had a plan of care for physical therapy (PT) to visit one (1) time per week for one (1) week, two (2) times per week for two (2) weeks and one (1) time per week for one (1) week. On the fourth week of services (3/13/2022), the PT failed to make a visit. On 3/17/2022 the PT documented “no answer and voice mail full, unable to leave a message”. There was no indication the PT made any further attempts to reach the patient and there was no documentation that the physician was notified. An interview with the administrator, staff #1, on 5/26/2022 at 11:30 am revealed the administrator was unable to provide evidence of further attempts to reach the patient and no notification was made to the physician. 2. Clinical record #9 was reviewed for the certification period of 4/15/2022 through 6/13/2022. The patient had a plan of care for Oxygen 2-4 L (liter)via nasal cannula prn (as needed). A review of nursing and physical therapy notes during that certification period revealed the patient was getting Oxygen at 1(liter) via nasal cannula continuous without an order. An interview with the administrator, staff #1, on 5/26/2022 at 11:30 am revealed there was no order to change the Oxygen concentration and the administrator acknowledged the wrong concentration was being documented in the clinical notes.