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

An unannounced Home Health Agency recertification survey was conducted on January 9-11, 2023, 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 Recertification survey was conducted at the above noted agency January 9-11, 2023, by one (1) Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 559 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, (13) clinical records and seven (7) personnel files were reviewed and five (5) home visits and were conducted. The agency was found to be out of compliance with the Federal requirements of 42 CFR 484, the Medicare/Medicaid Conditions for Certification of Home Health Agencies. 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 a review of clinical records and agency's admission process policy, it was determined the agency failed to ensure patients were informed about and consented to the disciplines that will furnish the care and/or the frequency of proposed visits in advance of starting care for four (4) of (13) patients in the survey sample (Clinical records #'s: 6, 7, 10 and 12). The findings: Thirteen electronic clinical records were reviewed in read only mode January 09-11, 2023. The informed consent signed at the time of admission and prior to services being provided for patient #6 with a start of care date of 11/06/2022 failed to contain documentation of the frequency of Skilled Nursing and Physical Therapy services the patient would be receiving. The informed consent signed at the time of admission and prior to services being provided for patient #7 with a start of care date of 06/23/2022 failed to contain documentation of the frequency of Skilled Nursing, Occupational Therapy and Physical Therapy services the patient would be receiving. The informed consent signed at the time of admission and prior to services being provided for patient #10 with a start of care date of 11/25/2022 failed to contain documentation of the frequency of Skilled Nursing and Physical Therapy services the patient would be receiving. The informed consent signed at the time of admission and prior to services being provided for patient #12 with a start of care date of 12/08/2022 failed to contain documentation of the frequency of Skilled Nursing and Physical Therapy services the patient would be receiving. The agency's policy, Admission Process 2.1.001 partially reads as follows: "informs patient/caregiver of anticipated services and frequency." The lack of documentation at the time of admission and prior to services being provided regarding the frequency of services to be provided was reviewed with the Executive Director prior to and during the exit conference on 01/11/2023.

Payment from federally funded programs CFR(s): 484.50(c)(7)(i, ii, iii, iv) Be advised, orally and in writing, of- (i) The extent to which payment for HHA services may be expected from Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (ii) The charges for services that may not be covered by Medicare, Medicaid, or any other federally-funded or federal aid program known to the HHA, (iii) The charges the individual may have to pay before care is initiated; and (iv) Any changes in the information provided in accordance with paragraph (c)(7) of this section when they occur. The HHA must advise the patient and representative (if any), of these changes as soon as possible, in advance of the next home health visit. The HHA must comply with the patient notice requirements at 42 CFR 411.408(d)(2) and 42 CFR 411.408(f). This ELEMENT is not met as evidenced by: Based on a review of clinical records and staff member interview, it was determined the agency failed to have written evidence of advising on the extent of payment by Medicare, Medicaid or any other federally funded or federal aid program known to the agency for services that maybe expected or may not be covered for one (1) of (13) patients in the survey sample (Client record #7). The findings: Thirteen electronic clinical records were reviewed in read only mode January 09-11, 2023. The informed consent signed at the time of admission and prior to services being provided for patient #7 with a start of care date of 06/23/2022 failed to contain an informed consent to include documentation of their financial liabilities. Interview: On 01/09/2023 this Medical Facilities Inspector asked the Executive Director where the rest of the consent was. The Executive Director stated, "That part of the consent was missing due to the patient admission packet did not have the correct consents but was caught later and corrected". The lack of documentation regarding the financial liability was acknowledged by the Executive Director during the medical record review and exit conference conducted on 01/11/2023.