Every finding on record at Area Agency on Aging of Western Arkansas, Inc.

On 05/18/2021 at 2:45 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 05/21/2021 at 12:30 PM 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, patient interview, and Agency staff interviews, the Skilled Nurse (SN) failed to ensure the patients Plan of Care (POC) included the required elements of all medication and treatments in 1 (#3) of 7 (#1 - #7) Clinical Records reviewed. This failed practice had the potential to result in harm for all patients on census by inhibiting the SN and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Findings follow: 1. Review of Clinical Record #3 revealed an Agency form titled "Plan of Care" with certification dates of 03/15/2021 through 05/13/2021 and a diagnosis of "Dependence on supplemental oxygen". An Agency form titled, "Patient Medication List" (the form the Agency used to list all medications the patient is taking), showed no evidence the Patient was using Oxygen (O2). 2. During a home visit and interview on 05/20/2021 at 10:35 AM with the Patient identified in Clinical Record #3, the Patient reported using O2 at a rate at 2 liters per minute. 3. During an interview on 05/21/2021 at 12:00 PM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation provided, Agency Personnel #2 confirmed the failure of the SN to include all medications on the POC and the "Patient Medication List". .

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 Records review and staff interviews, the Skilled Nurse (SN) failed to follow Physician orders for insertion of urinary catheter and treatments for 1 (#6) of 7 ( #1 through #7) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all 31 patients currently on census, in that patients may not receive treatments as ordered by the Physician which could result in adverse outcomes. Findings follow: 1. A review of Clinical Record #6 contained a document titled "Plan of Care" (POC) dated 04/27/2021 thru 06/25/2021" which included orders for "SN to insert urinary catheter using 16 FR [French] with 10 cc [cubic centimeter] balloon every month and PRN [as needed] if catheter occluded or dislodged." A review of a document titled "SN PRN [as needed] LPN [Licensed Practical Nurse] Visit" dated 5/10/2021 at 3:30 PM contained the following documentation, "SN removed old [named catheter brand], and inserted 18 FR Cath via sterile techniques...". 2. During an interview on 05/21/2021 at 12:00 PM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #2 confirmed the SN failed to comply with the Physician orders for urinary catheter change and stated "It's my fault, the Patient's catheter had been leaking and I told the nurse to just use what you have." .