Every finding on record at Arcadia Home Healthcare Services LLC

Emergency Preparedness Survey At the time of the emergency preparedness survey completed on 06/15/23, Arcadia Home Health is in compliance with the provisions of 42 CFR Part 484.102 Conditions of Participation for Home Health Agencies

Partial Extended Recertification Survey The following deficiencies are based upon the partial extended recertification survey completed on 06/15/23. Arcadia Home Healthcare Services, 369194, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agency.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on a record review, review of the outcomes and assessment information set (OASIS) transmissions, and staff interview, the facility failed to transmit OASIS data within 30 days of completing an assessment for two ( #3 and #5,) of two patients receiving skilled nursing services. This has the potential to affect all patients cared for by this agency receiving skilled services. Interview with Staff A during the entrance conference on 06/12/23 revealed a registered nurse (RN) gathers the OASIS data and this information is transmitted from the office by Staff A with Staff B being the back-up person. A request was made to Staff A for the transmission log for the past year. On 06/14/23 at 4:40 PM Staff A provided a transmission completed on 06/13/23. Staff A stated this agency has no record of log transmissions for OASIS. Staff A stated this agency has had only two skilled patients in the past year. The medical record for Patient #3 was reviewed on 06/13/23. Patient #3 had a Start of Care (SOC) date of 03/02/22 with a primary diagnosis of Alzheimer's disease and unspecified abnormalities of gait and mobility. The certification period reviewed was for 04/26/23-06/24/23. Skilled nurse (SN) services were ordered one time per week and home health aide (HHA) was ordered 60 hours per week. The medical record had OASIS assessments completed on 03/30/23 and 06/02/23. There was no evidence this was transmitted. Review of the record for Patient #5 was reviewed on 06/14/23. Patient #5 had a SOC of 08/17/20 with a primary diagnosis of chronic obstructive pulmonary disease (COPD) and Type II diabetes. The certification period reviewed was for 04/04/23-06/02/23 and 06/03/23 - 08/01/23 with skilled nursing ordered weekly and HHA 14 hours per week. There was no evidence of any OASIS transmission. The facility policy titled "OASIS Information," October 2017 revealed the agency was to electronically transmit completed, encoded and locked OASIS data for each completed OASIS assessment at least monthly to the system. Interview on 06/15/23 at 11:40 AM, Staff A verified the OASIS collection was completed but no submissions were made within the required 30 days for either of these patients.

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 medical record review, policy review, observations during home visits and staff interview, the agency failed to identify all medications that patients are taking. This affected three patients (#1, #2 and #3) with the potential to affect all patients cared for by this agency. 1. The medical record for Patient #1 was reviewed on 06/12/23. Patient #1 had a Start of Care (SOC) of 01/25/22 with a primary diagnosis of generalized epilepsy and hypertension. The certification period reviewed was for 03/21/23-05/19/23 and 05/20/23-present (06/23/23). A home health aide (HHA) was ordered for 42 hours per week with six hours per day provided. A home visit was completed on 06/13/23. Medications in the home were reviewed with the medication profile. The following medications were observed in the home which were not listed on the medication profile:. Tramadol 50 milligrams (mg) as needed for pain, Vitamin D3 two times per day with the prescription bottle listing a date of 2/10/23, aspirin 81 mg one per day, and Potassium chloride (KCl) one every day with a start date of 09/15/22. Interview at the time of the home visit with the HHA, who is this client’s granddaughter, stated these medications are not new and this client is taking them every day. Review of the facility policy titled "Medication Reconciliation," October 2017, instructes the skilled nurse (SN) to update the medication profile with each new or changed medication. This policy further instructs the SN to update the medication list in the home. The findings of the nurse not updating the medication profile with the weekly visits as the policy instructs was verified during an interview with Staff A and Staff B on 06/13/23 at 2:15 PM. 2. The medical record for Patient #2 was reviewed on 06/13/23. Patient #2 had a SOC of 01/17/20 with a primary diagnosis of multiple sclerosis. The certification period reviewed was for 05/01/23-06/29/23 with a HHA ordered for 35 hours per week. The medication profile included Naprosyn 500mg and omeprazole 20 mg. Recertification in the medical record stated the medication profile was updated A home visit was competed on 06/13/23 at 10:40 AM with a HHA who was this client’s son. Medications were reviewed with the client which were compared with the medication profile. Patient #2 stated they have not taken or refilled the Naprosyn 500 mg for some time and have not taken the omeprazole 20 mg for the past year. Interview with Staff A and B on0 6/13/23 at 2:15 PM confirmed the agencies policy for medication review was not followed. 3. The medical record for Patient #3 was reviewed on 06/13/23. Patient #3 had a SOC of 03/02/22 with a primary diagnosis of Alzheimer's disease and unspecified abnormalities of gait and mobility. The certification period reviewed was for 04/26/23-06/24/23 with SN services ordered one time per week and HHA 60 hours per week. The medical record showed skilled nurse visits were completed weekly with notes stating medications reviewed. The medication profile revealed the patient was on aspirin and did not include sertraline. A home visit was completed on 06/13/23 at 1:00 PM with the SN and aide present. The medication profile was reviewed with this client’s daughter during this visit. The client’s daughter stated the aspirin was stopped three months ago and sertraline 100 mg at bedtime was started on 05/08/23. The findings of not updating the medication profile during the weekly SN visits as policy instructs was verified during an interview with Staff A and Staff B on 06/13/23 at 2:15 PM.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on medical record review, policy review and staff interview, the facility failed to complete home visits every 14 days by a nurse for patients receiving skilled nursing (SN) services. This affected two patients (#3 and #5) with the potential to affect all patients cared for by this agency. 1. The medical record for Patient #3 was reviewed on 06/13/23. Patient #3 had a Start of Care (SOC) of 03/02/22 with a primary diagnosis of Alzheimer’s disease and unspecified abnormalities of gait and mobility. The certification period reviewed was for 04/26/23-06/24/23 with skilled nurse (SN) services ordered one time per week and home health aide (HHA) 60 hours per week. Supervisory visits were completed during each of the certification periods every 60 days. The most recent SV was completed by Staff C on 04/24/23 and not again until 06/14/23. The 06/14/23 visit was not documented in the medical record, but was documented as completed on the HHA supervisory visit. No other on-site visits were noted in the medical record. The facility policy titled "Home Health Aide Supervision," was provided on 06/15/23 at 9:50 AM. This policy lists as its purpose to assure the appropriateness of home health aide services and to maintain quality of care. If an area of concern in aide services is noted by the supervising registered nurse or other appropriate skilled professional, then the supervising individual will make an on-site visit to the location where the patient is receiving care to observe and assess the aide while he or she is performing care. 2. The medical record for Patient #5 was reviewed on 06/14/23. Patient #5 had a SOC of 08/17/20 with a primary diagnosis of chronic obstructive pulmonary disease. Skilled nurse visits were scheduled weekly and HHA scheduled 14 hours per week. The medical record revealed an onsite visit was completed by Staff C on 06/02/23 with an evaluation but no other onsite visits were were noted in the record. Interview on 06/15/23 at 1:45 PM, Staff A and Staff B verified onsite nursing visits were not completed every 14 days for skilled patients receiving home health aide services.