Every finding on record at Wythe County Community Hospital

An unannounced Home Health Agency recertification survey was conducted on March 20 and 22-23, 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 March 20 and 22-23, 2023 by one Medical Facilities Inspectors from the Office of Licensure and Certification, Virginia Department of Health. The agency identified 580 unduplicated admissions for the past twelve (12) months. In conjunction with the survey, (13) clinical records and nine (9) personnel files were reviewed. Five (5) home visits and were conducted. The agency was found to not be in 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.

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on staff interview and document review, it was determined the agency failed to ensure a patient received proper written notice, in advance of a specific service being furnished, if the HHA believed that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. Specifically, the agency failed to provide written, advanced notice prior to discharging a patient in one (1) of four (4) patient records reviewed of patients with agency discharges (Client record #3). Findings: Four (4) discharge/closed electronic clinical records were reviewed in the agency from 03/22-03/23/2023 via read only access. 1. The clinical record for patient #3 contained a documented date of discharge of 06/21/2022 due to non-compliance. The clinical record failed to contain evidence that the agency made efforts to resolve the problems or advised the patient with written/verbal, advance notice of discharge. The agency's policy located in the patient admission packet, Transfer & Discharge Policy partially reads as follows: "We determine a discharge for cause is appropriate because your behavior is disruptive, abusive, or uncooperative to the extent that delivery of your care or our ability to operate effectively is seriously impaired. In the event a discharge for cause is being considered the agency will: Advise you, your legal representative, your physician ordering services, your primary care physician or other health care professional responsible for your care after discharge that a discharge for cause is being considered; Attempt to resolve problem presented by your behavior or other persons in your home's behavior; Provide you or your legal representative contact information for other agencies; Document the problems and efforts made to resolve the problems " The Administrator acknowledged the above noted deficiency during the exit conference on 03/23/2023.