Every finding on record at Aaa Southeast Ar Drew Co

On 4/05/2022 at 09:13 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 04/07/2022 at 12:20 PM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. The Agency was determined to be in out of compliance with the 42 CFR Part 484 Conditions of Participation for Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications during the review of the patient's medications in 1 (# 2) of 7 (#1-#7) clinical records reviewed. This failed practice by the SN posed a risk of potential harm for all patients prescribed Oxygen by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. A review of Clinical Record #2 revealed the following: A. Document titled, "Home Health Care Certification and Plan of Care" (POC) dated 02/17/22- 04/17/22 show." Client states she has not used the oxygen within the last week" B. Document titled "Client Medication Report" did not list Oxygen to be included in the review for adverse effects, drug reactions, significant side effects or significant drug interactions. C. During an interview on 4/7/2022 at 12:20 PM, Agency Representatives were provided an opportunity to present additional documentation. Agency Personnel #2 confirmed the Agency staff did not review all medications for adverse effects, drug reactions, significant side effects and significant drug interactions for patient #2

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview it was determined Agency staff Clinicians failed to include parameters of what constitute a significant change in patient condition of when to notify the physician in 3 (#1, #2, and #6) of 7 (#1 - #7) Clinical Records reviewed. This deficient practice had the potential to prevent the patient from receiving appropriate care and delay attainment of personal goals. 1. Review of Patient #1 Clinical Record revealed the following: A. A patient with a primary diagnosis of “Hypertension Chronic Kidney Disease” and pertinent diagnosis of “Hemiplegia/hemiparesis following cerebral infarction.” B. A document titled, “Home Health Certificate and Plan of Care” (POC) dated 5/05/21 – 7/03/2021 showed orders for SN (skilled nurse) Observation/Assessment Hypertension teach and assess s/s (signs and symptoms) Hypotension/Hypertension, medication and side effects of Hypertension drugs and vital signs that are out of range for client. C. There are no parameters on the POC of what constitutes a significant change in patient blood pressure of when to notify the physician. D. During an interview on 4/07/2022 at 12.20 PM, Agency Representative were provided an opportunity to present additional documentation. Agency Staff # 1 confirmed the Agency did not include parameters for blood pressure on the POC of when to notify the physician. 2. Review of Patient #2 Clinical Record revealed the following: A. A patient with a primary diagnosis of “Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy.” B. A document titled, “Home Health Certificate and Plan of Care” (POC) dated 2/17/2022 – 4/17/2022 showed orders for SN (skilled nurse) Observe and assess for diabetic status: evaluate blood sugars from client’s record, reiterate diet with no concentration sweets. C. There are no parameters on the POC of what constitutes a significant change in patient blood glucose of when to notify the physician. D. During an interview on 4/07/2022 at 12.20 PM, Agency Representative were provided an opportunity to present additional documentation. Agency Staff # 1 confirmed the Agency did not include parameters for blood glucose on the POC of when to notify the physician. 3. Review of Patient #6 Clinical Record revealed the following: A. A patient with a primary diagnosis of “Generalized (Osteo) Arthritis” B. A document titled, “Home Health Certificate and Plan of Care” (POC) dated 2/03/22 – 4/03/2022 showed orders for SN (skilled nurse ) to assess for complaints of pain, increased pain or pain not relieved with current medication regimen, increased weakness, falls or injuries. C. A document titled, “Home Health Certificate and Plan of Care” (POC) dated 2/03/22 – 4/03/2022 showed medication of Apap (Acetaminophen)/Codeine 300/30 take one tablet by mouth every six hours as needed for pain PO. D. A document titled, “Pain Assessment /Management Policy “ showed pain will be treated as a “vital sign” and agency will strive to ensure that pain is measured and treated. The nurse/therapist will use a standard agency accepted pain assessment tool that evaluates the location, duration, severity (rating scale)… E. There are no parameters on the POC of what constitutes a significant change in patient pain of when to notify the physician. F. During an interview on 4/07/2022 at 12.20 PM, Agency Representative were provided an opportunity to present additional documentation. Agency Staff # 1 confirmed the Agency did not include parameters on the POC of what constitutes a significant change in patient pain of when to notify the physician.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview it was determined Agency staff Clinicians failed to notify the Physician when the updated Comprehensive Assessment indicated a change in condition in 1 (#1) of 7 (#1 - #7) Clinical Records reviewed. This deficient practice had the potential to prevent the patient from receiving appropriate care and delay attainment of personal goals. 1. Review of Patient #1 Clinical Record revealed the following: A. A patient with a pertinent diagnosis of "Type2 Diabetes Mellitus". B. A document titled, "Home Health Certification and Plan of Care" (POC) dated 5/05//21 - 7/03/22 showed orders for “S/N (skilled nurse) to report any blood sugars above 300 or below 60 to MD. C. A document titled "Service Note" dated 05/10/21 showed documentation of a blood glucose reading of 364. D. There was no evidence the SN notified the physician of the out of parameter finding. E. During an interview on 4/07/2022 at 12.20 PM, Agency Representative were provided an opportunity to present additional documentation. Agency # 2 confirmed the Agency staff did not notify the physician of changes in client's condition.