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

One Medical Facilities Inspector (MFI) from the Office of Licensure and Certification (OLC), Virginia Department of Health (VDH) conducted an unannounced Home Health Medicare Recertification Survey on August 30-September 01, 2021. As part of the inspection process, the agency's Emergency Preparedness Plan was reviewed. The agency was found to be in compliance with 42 CFR 484.113, the Condition of Participation - Emergency Preparedness for Home Health Agencies.

An unannounced Medicare/Medicaid Home Health Recertification survey was conducted at the above noted agency August 30-September 01, 2021 by one Medical Facilities Inspector from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 541 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, (13) clinical records and five (5) personnel files were reviewed. Five (5) home visits were also 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.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on a review of clinical records and interviews it was determined the agency's staff failed to follow the individualized plans of care for three (3) of (13) patients whose records were reviewed in the survey sample (Clinical records# 1, 6, and 12). The findings: Thirteen clinical records were reviewed with read only access 8/30-31/2021 with the following findings: 1. The clinical record for patient #1 was reviewed for the certification period of 6/15/2020 to 8/13/2020. Skilled nursing services was ordered for two (2) times per week for two (2) weeks after the resumption of care of 6/25/2020. The clinical record contained documentation of less than 2 visits per week as noted below; - One (1) SN visit was documented for the week of 7/12/2020 through 7/18/2020 (week 5 for SN) - One (1) SN visit was documented for the week of 7/19/2020 through 7/25/2020 (week 6 for SN) On 9/1/2021, at 11:00 AM the Executive Director verified the missed SN visits for the above noted finding. The clinical record failed to contain documentation that the patient's physician was notified of the visits not being provided in accordance with the patient's plan of care. 2. The clinical record for patient #6 was reviewed for the certification period of 8/8/2021 to 10/6/2021. The plan of care contained an order for the SN to obtain a body measurement of abdominal girth and notify physician of a 3 inch increase. The clinical record failed to contain abdominal girth measurement documentation for this certification period. On 9/1/2021 at 10:0 AM, this MFI asked staff member #2 where was the patient's abdominal girth measurements? Staff member #2 stated, if we weigh them, then we don't do abdominal girth, we only do abdominal girth(s) when the patient cannot be weighed. The MFI explained to staff member #2 in the presence of the Executive Director that plan of care did not state this. The clinical record failed to contain documentation that the patient's physician was notified of abdominal girth measurements were not being conducted and documented in accordance with the patient's plan of care. 3. The clinical record for patient #12 was reviewed for the certification period of 7/31/2021 to 9/28/2021. The plan of care contained an order for the SN to obtain body measurement(s) of the abdominal girth and notify the physician of any 3 inch increase. The clinical record failed to contain abdominal girth measurement documentation for this certification period except for the start of care. The clinical record failed to contain documentation that the patient's physician was notified of abdominal girth measurements were not being conducted and documented in accordance with the patient's plan of care. The lack of documentation regarding services being provided according to the above noted plans of care and physician orders was reviewed and acknowledged by the Executive Director on 9/1/2021 at 12:00 PM.