Every finding on record at Ar Methodist Medical Center Home Health Agency

On 06/10/24 at 2:30 PM, 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. The general nature of the survey process and expected length of survey explained. On 06/14/24 at 11:30 AM, an exit survey was conducted with Agency Representatives. Preliminary findings of the survey were discussed. The Agency Representatives were given the opportunity to present additional information for the findings discussed. No additional information was presented.

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 interview, it was determined the Skilled Nurse (SN) failed to obtain orders and include all medications utilized by the patient on the medication list in 1 (#2) of 12 (#1-#12) clinical records reviewed. This failed practice presented a potential risk to all patients currently on census as the failure to conduct a medication review inhibited the patient's attending physician from making an informed decision regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. The findings are as follows: Review of clinical record #2 with a start of care of 05/20/24 revealed a patient with the diagnosis of Chronic Obstructive Pulmonary Disease. Review of a document titled LPN/LVN-Skilled Nursing Visit and dated 05/30/2024 revealed documentation of "ASSESSMENT AND EDUCATION ON NEW MEDICATION BUMETANE GIVEN." No documentation in the patient's clinical record of a physician's order for the new medication or evidence the medication was checked for potential adverse effects, drug reactions, significant side effects or significant drug interactions. An interview on 06/11/24 at 3:30 PM with Agency Personnel #1 confirmed the failure to obtain orders or conduct a medication review on a new medication.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to obtain orders for a foley catheter in 1 (#8) out of 12 (#1-#12) clinical records reviewed. This failed practice presented a potential risk to all patients currently on census, in that patients may not receive treatments only as ordered by the Physician and this could result in adverse outcomes. Findings as follows: Review of clinical record #8 with a start of care of 05/23/24 revealed a patient with a diagnosis of Hypertensive Heart & Chronic Kidney Disease with Heart Failure. Review of a document titled "Skilled Nursing Visit" and dated 05/24/2024 states "SN CHANGED FOLEY CATHETER USING STERILE TECHNIQUE". Review of a document titled "Home Health Certification and Plan of Care" with a certification period of 05/23/24 to 07/21/2024 orders include "DME (Durable Medical Equipment) & Supplies Foley Catheter.....Drainage Bag......Leg Bag...". No physician's order to insert or change a foley catheter. An interview on 05/12/24 at 3:30 PM with Agency Personnel #1 confirmed the patient had a foley catheter and it was changed without a physician's order.

Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient's needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview it was determined the agency failed to coordinate care delivery to ensure physical therapy services provided in 1 (#3) out of 12 (#1-#12) clinical records reviewed. This failed practice resulted in a delay in the initiation of physical therapy services and had the potential to affect all patients currently on census with a potential risk for decreased mobility and increased risk of falls. The findings are as follows.: Review of clinical record #3 with a start of care of 05/17/24 revealed a patient with a diagnosis of Pressure Ulcer Right Buttock Stage II (Stage 2: Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough or bruising. May also present as an intact or open/ruptured blister.) Review of a document titled “LPN/LVN-Skilled Nursing Visit” and dated 06/04/2024 revealed “PATIENT IS VERY UNSTABLE WITH AMBULATION EVEN WITH ROLLING WALKER”. Skilled Nurse (SN) documented she talked to the patient about fall prevention and home physical therapy to which the patient was agreeable and notes “MD CALLED AND ORDERS OBTAINED”. No documentation in the patient’s clinical record of a physician’s order for physical therapy services or evidence of communication with the Physical Therapist to refer for evaluation. An interview on 06/12/24 with Agency Personnel #1 and #2 confirmed failure to coordinate care for physical therapy services with the Physician and the Physical Therapist.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview it was determined the clinical staff did not follow Physician orders for Home Health Aide (HHA) visit frequency in 1 (#2) of 12 (#1 - #12) records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census, in that patients may not receive treatments and services as ordered by the Physician which could result in adverse outcomes. Findings follow: Review of clinical record #2 with a start of care of 05/20/24 revealed a patient with a diagnosis of Chronic Obstructive Pulmonary Disease. Review of a document titled "Home Health Certification and Plan of Care" with a certification period of 05/20/2024 to 07/18/2024 revealed an order for "HHA (Home Health Aide): 2w9 (2 times per week for 9 weeks) FOR PERSONAL CARE". No documentation of home health aide visits assigned or completed. An interview on 06/12/24 at 3:15 PM with Agency Personnel #1 and #2 reports HHA ordered in error and visits were not assigned. Confirms failure to provide HHA services as ordered on the patient's plan of care.

. On 11/29/2021 at 12:50 PM, 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 12/03/2021 at 9:15 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

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 review of Clinical Records and staff interviews, the Agency did not ensure a Registered Nurse (RN) conducted a review of all medications in 2 (#2, and #7) of 10 (#1 through #10) Clinical Records reviewed. The Agency's noncompliance could potentially result in harm for all patients currently on census with new or changed medications inhibiting the RN and Physician from making informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. A review of the Medical record for Patient #2 contained a Skilled Nursing (SN) note dated 10/05/2021 showing documentation "He is on Linezolid [a medication used to treat an infection], for a UTI [ Urinary Tract Infection]." 2. Review of a document titled "Medication Profile" for Patient #2 dated 09/26/2021 - 11/26/2021, showed no evidence that the Linezolid was added to the list of medications or that this medication was checked for medication interactions with all other medications the Patient #2 was currently taking. 3. A review of the Medical record for Patient #7 contained a document titled "Home Health Certification and Plan of Care" dated 08/26/2021 to 10/24/2021 which revealed a diagnosis of "Dependence on Supplemental Oxygen." Also contained in the Medical record were multiple SN notes showing documentation of Patient #7 use of Oxygen. Review of document titled Medication Profile for Patient #2 dated 08/26/2021 - 10/27/2021 showed no evidence that Oxygen was listed on the Medication Profile and no evidence Oxygen was included in a review of Medication interactions. 4. A Review of the Medical record for Patient #7 contained a SN note dated 10/08/2021 with documentation, "Patient stated that Dr. (named Physician) has increased Hydralazine to three times a day for blood pressure." Review of the Medication Profile for Patient # 7 failed to show the Hydralazine dosage changed to three times a day nor reconciliation of the change to the Physician.

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 interviews, the Agency Staff did not include relevant patient specific interventions related to the patient's primary diagnosis to address the Patient's significant weight gain in 1 (#5) of 1(#5) Clinical Records reviewed for patients with a primary diagnosis of heart disease. The deficient practice identified, if continued could result in potential harm or risk of adverse outcomes or hospitalization for patients with diagnosis of Congestive Heart Failure by delaying the Skilled Nurse and Physician's ongoing assessment of patient needs and progression towards goals. 1. Review of Clinical Record #5 contained a document titled "Home Health Certification and Plan of Care" (POC) dated 11/10/2021 to 01/08/2021 which revealed a primary diagnosis as "Hypertensive heart disease with heart failure" and a secondary diagnosis of "Chronic systolic (congestive) heart failure". Interventions in the POC were for the Skilled Nurse (SN) to "instruct Patient on daily weight self monitoring program......" Goals in the POC were to educate the Patient/Caregiver on "daily weight self-monitoring program" and when to call emergency services. There were no interventions for the SN to monitor the patients weights. 2. The Clinical record contained SN notes dated 11/11/2021 which showed documentation that Patient #5 was "Short of Breath (SOB) with minimal exertion or with agitation." Weights were documented as "235.6" pounds (lbs.). SN visit note dated 11/12/2021 contained documentation that Patient #5 was SOB "At rest" and documentation of weight at "240.6" a weight gain of 5 pounds over the 24 hour period from SN visit on 11/11/2021 and SN visit 11/12/2021. 3. During an interview on 12/03/2021 at 8:45 AM Personnel #1 and #2 stated to the Surveyor that a document titled "Living with Congestive Heart Failure" and American Heart Association recommendations to be utilized by the Agency and Staff for Parameters regarding weight changes for Patient's with Congestive Heart Failure. This document showed that the Patient would be in the "Red Zone if weight gain was 5 lbs. or greater." Personnel #1 and #2 reported the "Red Zone" as significant changes in the patient's condition and the Physician should be notified of such weight gain. With no further documentation presented by Agency staff, Personnel #1 and #2 verified the POC did not include patient specific interventions in Patient #5's condition and the patient's Primary Physician was not notified of patient's increased weight change..

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: . Based on Clinical Record review, and staff interview the Agency failed to ensure a complete Discharge/Transfer Summary was sent to the Physician after discharge in 1 (#6) of 3 (#6 - #8) Clinical Records reviewed with transfer/discharge status. This failed practice had the potential to place this Patient risk by preventing effective and efficient coordination of care among health care team members and providers. Findings follow: 1. Review of Clinical Record #6 for a certification period of 10/15/2021 to 12/13/2021 showed the Patient was discharged from the Agency on 11/18/2021. There was no evidence a discharge summary was completed for Patient #6. 2. During an interview on12/03/2021 at 8:45 A.M., Agency Personnel were given an opportunity to present additional documents and Agency Personnel #2 stated the discharge summary was not completed and sent to the Physician.