Every finding on record at Area Agency on Aging of SE Ar Inc

On 5/24/2022 at 09:35 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 05/27/2022 at 09:30 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

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 failed to obtain a complete order on the Plan of Care in 1 (#3) 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. Review of Clinical Record #3 revealed the following: A. A patient with a primary diagnosis of Encounter for fitting and adjustment of urinary device" B. A document titled, “Home Health Certificate and Plan of Care” (POC) dated 04/08/22 – 5/23/2022 showed orders for SN (skilled nurse) to change catheter 1 x month and prn (as needed) C. There was no evidence the agency specified catheter type, size, and balloon size. D. During an interview on 5/27/2022 at 09.30 AM, Agency Personnel were provided an opportunity to present additional documentation. Agency Personnel # 1 confirmed the Agency did not include catheter and balloon size on the POC.

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 the Agency staff did not follow the Attending Physician orders contained in the Plan of Care (POC) for 2 (#5, and #7) of 7 (#1 - #7) Clinical Records reviewed. This failed practice if not corrected had the potential of increased risk of hospitalizations due to disease exacerbation. 1. Review of Clinical Record #5 revealed the following: A. A patient with a primary diagnosis of "Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 5 Chronic Kidney Disease." B. A document titled, “Home Health Certificate and Plan of Care” (POC) dated 3/25/22 – 5/23/2022 showed orders for SN (skilled nurse) to prefill 2 weeks dispenser and report missed doses of greater than 5 doses to PCP (Primary Care Physician) C. A document titled, “Nurses Note” dated 5/09/2022 reported 14 missed doses of medication. D. There was no evidence the Agency staff notified the physician of the greater than 5 missed doses as ordered in the POC. 2. Review of Clinical Record #7 revealed the following: A. A patient with a primary diagnosis of "Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Chronic Kidney Disease." B. A document titled, “Home Health Certificate and Plan of Care” (POC) dated 5/13/22 – 7/11/2022 showed orders for SN (skilled nurse) to notify physician of systolic blood pressure (greater than)160. C. A document titled, “Nurses Note” dated 5/20/2022 reported blood pressure reading of 172/92. D. There was no evidence the Agency staff notified the physician of systolic BP (Blood Pressure) greater than 160 as ordered in the POC D. During an interview on 5/27/22 at 9:15 AM, Agency Personnel were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the Agency staff’s failed to follow the Attending Physician orders contained in the POC in Patient #5 and #7.