Avalon in Home Nursing and Rehabilitation LLC

“Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This Element is not met as evidenced by: Based on personnel file review, and interviews, it was determined the agency failed to immediately remove a staff member from patient care due to allegations of misconduct related to abuse. Specifically, an employee of the agency was not removed from patient care for (19) days after an allegation of sexual misconduct of a patient for one (1) of six (6) patients in the survey sample (Clinical record for Patient #1). Findings: The clinical record for Patient #1 was reviewed for the period of July 19, 2024 to July 31, 2024. The clinical record indicated Staff Member #3 was the only visiting staff member. The clinical record did not indicate any documentation of inappropriate or sexual misconduct. Patient #1 was discharged from the agency on July 31, 2024 by Staff Member #3 with all goals met for therapy. On October 28, 2024 at 3:48 PM the Medical Facilities Inspector (MFI) conducted an interview with Staff Member #1. Staff Member #1 revealed that Staff Member #3 usually makes all therapy visits as in (name redacted) Patient #1’s case due to it is only two (2) PTA’s (Physical Therapy Assistant) available in that service area and Staff Member #3 prefers not to supervise the PTA’s. The personnel file for Staff Member #3 was reviewed on October 28, 2024. The personnel file contained a typed and signed letter by Staff Member #3 dated October 12, 2024. The letter indicated Staff Member #3’s attestation of the events on July 31, 2024 as discharging Patient #1 from therapy, hugging, and kissing. Staff Member #3 indicated they both sat on the couch and continued kissing, leading to kiss Patient #1’s (part of body redacted) and touched their (genitalia redacted). Patient #1 asked me if we could stop and I stopped right away. The following afternoon Patient #1 called and Staff Member #3 called Patient #1 back. Staff Member indicated Patient #1 sounded mad and upset asking multiple times why I kissed “them”. Staff Member #3 indicated they were sorry if “their” feelings were hurt and never forced “them” to do anything, and I even asked “them” multiple times if “they” was ok, which “they” replied am fine. The call ended with Patient #1 telling me to not call “them” back ever again. I did not contact “them” again. Staff Member #3’s “Disciplinary Action for Unprofessional Conduct” was dated October 16, 2024 with an indefinite suspension. Staff Member #3’s personnel file was reviewed further for any previous conviction data as follows: “Criminal Record Check” of February 24, 2020 contained no Virginia Conviction Data or no Virginia Sex Offender Registration Record. “A National Sex Offender Public Website from The United States of Department of Justice” contained no records from Virginia dated February 27, 2020. The “Virginia Department of Health Professions License Lookup” indicated a current active license status with no additional public information. The personnel file was reviewed for agency policies and procedures as follows: Staff Member #3 signed and dated the “Acknowledgement of Mandated Reporter Status” on January 22, 2020. A “Code of Business Ethics and Compliance” revised on August 01, 2023 and signed by Staff Member #3 on September 03, 2023. On September 03, 2023, Staff Member #3 signed the “Sexual Harassment and Discrimination” revised on March 23, 2023. An “Independent Contractor Service Agreement “revised on July 12, 2023 and signed by Staff Member #3. The MFI reviewed the agency’s policy and procedures to ensure the agency has a system in place to protect patients from abuse, neglect and misappropriation of property from staff as follows: -“Acknowledgement of Mandated Reporter Status” read in part as: I am required to report or cause a report to be made to the Virginia Adult Protective Services (APS) either by calling APS or the appropriate local department of social services whenever I have reasonable cause to suspect that an adult aged 60 or over or an incapacitated adult aged 18 and over who is known to me in my professional or official capacity may be abused, neglected, or exploited. I understand that I must follow the reporting protocol, if any, to my employer, but my employer may not prohibit me from reporting directly to APS. -“Patient Visit Rules” that read in part as: While it is impossible to list every type of behavior that may be deemed a serious offense, these visit rules include examples that may result in disciplinary actions up to including termination of contract. Any willful act or conduct that jeopardizes the welfare of patient’s. -“Code of Business Ethics and Compliance” revised on August 01, 2023 read in part as follows: 18. It is a violation of this Code for employees, independent contractors and or vendors not to report a violation of the Code or to fail to report any wrongdoing or suspected wrongdoing. 19. It is (agency name redacted) policy to promptly and thoroughly investigate reports of wrongdoing or suspected wrongdoing or violations of this Code. Employees must cooperate with these investigations 20. Employees, contractors, or vendors who violate the Code or commit illegal acts are subject to discipline up to and including dismissal. - “Sexual Harassment and Discrimination” revised on March 23, 2023 that read in part as: Each employee is responsible for creating an environment free from harassing conduct. Harassment can be either sexual or non-sexual conduct that is offensive, fails to respect the rights of others or interferes with work. Examples of sexual harassment include, but not limited to the following: Unwanted or unnecessary physical contact, sexual touching, brushing up against another in a sexual manner, graphic or sexually suggestive gestures, cornering, pinching, grabbing, kissing, or fondling. Procedure-2. Any employee who violates the policy against sexual harassment, or encourages another to violate the policy, will be subjected to appropriate disciplinary action depending on the severity and type of violating behavior, up to and including discharge. -“Independent Contractor Service Agreement “revised on July 12, 2023 read in part as: c. Contractor shall comply with all policies, procedures, rules and regulations, both written and oral, as communicated by the Company from time-to-time d. Contractor shall render reasonable and appropriate treatment to every patient presented, consistent with professional standards and within Therapist scope of practice. 17. Contractor acknowledges that (agency name) is required by statue to report to the Virginia Department of Health Professions certain conduct and/or disciplinary action with respect to any Contractor subject to regulation by the health regulatory board. The above policies and procedures indicated the agency has a system in place to protect patients from abuse, neglect and misappropriation of property from staff. On October 28, 2024 at 4 PM the MFI conducted an interview with Staff Member #4. Staff Member #4 revealed that Patient #1 did not lodge a complaint with the agency but was contacted by the County Police Detective (name redacted). The Detective reported the complaint to the agency on September 27, 2024. Staff Member #4’s interview revealed Staff Member #3’s alleged sexual assault was reported to the agency on September 27, 2024 and Staff Member #3 was suspended from the agency on October 16, 2024. The agency did not immediately remove Staff Member #3 from patient care until (19) days after the allegation of sexual misconduct.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on review of personnel file, agency policies and procedures and the Unprofessional Conduct of the Code of Virginia, it was determined that the agency Staff Member #3 failed to provide accepted professional standards of practice in one (1) of six (6) clinical records in the survey sample (Clinical record for Patient #1). Findings: The personnel file for Staff Member #3 was reviewed on October 28, 2024. The personnel file contained a typed and signed letter by Staff Member #3 dated October 12, 2024. The letter indicated Staff Member #3’s attestation of the events on July 31, 2024 as discharging Patient #1 from therapy, hugging, and kissing. Staff Member #3 indicated they both sat on the couch and continued kissing, leading to kiss Patient #1’s (part of body redacted) and touched their (genitalia redacted). Patient #1 asked me if we could stop and I stopped right away. The following afternoon Patient #1 called and Staff Member #3 called Patient #1 back. Staff Member indicated Patient #1 sounded mad and upset asking multiple times why I kissed “them”. Staff Member #3 indicated they were sorry if “their” feelings were hurt and never forced “them” to do anything, and I even asked “them” multiple times if “they” was ok, which “they” replied am fine. The call ended with Patient #1 telling me to not call “them” back ever again. I did not contact “them” again. Staff Member #3’s “Disciplinary Action for Unprofessional Conduct” was dated October 16, 2024 with an indefinite suspension. The personnel file was reviewed for agency policies and procedures as follows: Staff Member #3 signed and dated the “Acknowledgement of Mandated Reporter Status” on January 22, 2020. The Acknowledgment read in part as: I am required to report or cause a report to be made to the Virginia Adult Protective Services (APS) either by calling APS or the appropriate local department of social services whenever I have reasonable cause to suspect that an adult aged 60 or over or an incapacitated adult aged 18 and over who is known to me in my professional or official capacity may be abused, neglected, or exploited. I understand that I must follow the reporting protocol, if any, to my employer, but my employer may not prohibit me from reporting directly to APS. Staff Member #3 signed the Physical Therapist job description on January 22, 2020 that read in part as: Is responsible for adhering to all practice standards as they apply to patient care. The personnel file also contained a “Patient Visit Rules” and signed on January 22, 2020, that read in part as: While it is impossible to list every type of behavior that may be deemed a serious offense, these visit rules include examples that may result in disciplinary actions up to including termination of contract. Any willful act or conduct that jeopardizes the welfare of patient’s. A “Code of Business Ethics and Compliance” revised on August 01, 2023 and signed by Staff Member #3 on September 03, 2023 read in part as follows: 18. It is a violation of this Code for employees, independent contractors and or vendors not to report a violation of the Code or to fail to report any wrongdoing or suspected wrongdoing. 19. It is (agency name redacted) policy to promptly and thoroughly investigate reports of wrongdoing or suspected wrongdoing or violations of this Code. Employees must cooperate with these investigations 20. Employees, contractors, or vendors who violate the Code or commit illegal acts are subject to discipline up to and including dismissal. On September 03, 2023, Staff Member #3 signed the “Sexual Harassment and Discrimination” revised on March 23, 2023 that read in part as: Each employee is responsible for creating an environment free from harassing conduct. Harassment can be either sexual or non-sexual conduct that is offensive, fails to respect the rights of others or interferes with work. Examples of sexual harassment include, but not limited to the following: Unwanted or unnecessary physical contact, sexual touching, brushing up against another in a sexual manner, graphic or sexually suggestive gestures, cornering, pinching, grabbing, kissing, or fondling. Procedure-2. Any employee who violates the policy against sexual harassment, or encourages another to violate the policy, will be subjected to appropriate disciplinary action depending on the severity and type of violating behavior, up to and including discharge. In addition, an “Independent Contractor Service Agreement “revised on July 12, 2023 and signed by Staff Member #3 read in part as: c. Contractor shall comply with all policies, procedures, rules and regulations, both written and oral, as communicated by the Company from time-to-time d. Contractor shall render reasonable and appropriate treatment to every patient presented, consistent with professional standards and within Therapist scope of practice. 17. Contractor acknowledges that (agency name) is required by statue to report to the Virginia Department of Health Professions certain conduct and/or disciplinary action with respect to any Contractor subject to regulation by the health regulatory board. According to “§ 54.1-3483 Unprofessional conduct of the Code of Virginia” sexual contact includes, but is not limited to, sexual behavior or verbal or physical behavior that: 1. May reasonably be interpreted as intended for the sexual arousal or gratification of the practitioner, the patient, or both; or 2. May reasonably be interpreted as romantic involvement with a patient regardless of whether such involvement occurs in the professional setting or outside of it. 10. Engages in sexual contact with a patient concurrent with and by virtue of the practitioner/patient relationship or otherwise engages at any time during the course of the practitioner/patient relationship in conduct of a sexual nature that a reasonable patient would consider lewd and offensive. (https://law.lis.virginia.gov/vacode/54.1-3483/). The personnel file contained Staff Member #3’s attestation of events that indicated sexual misconduct; an indefinite suspension from the agency on October 16, 2024; all policies and procedures were signed during the date of hire (January 22, 2020) and ongoing until the suspension of October 16, 2024 regarding unacceptable behaviors, professional standards including Mandated Reporter Status, Code of Business Ethics and Compliance and Sexual Harassment and Discrimination. Staff Member #3 failed to follow the agency’s policies and procedures regarding sexual misconduct.”