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

On 11/28/2023 at 12:35 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 11/30/2023 at 10:30 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

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 Agency staff interview it was determined the Skilled Nurse (SN) failed to alert the Physician of relevant assessment findings which may have necessitated an alteration in the Plan of Care (POC) in 2 (#4 and #8) of 8 (#1 - #8) Clinical Records reviewed. This failed practice had the potential to affect all current patients on census in that Physicians may be unaware of new assessment findings resulting in missed opportunities for revision of patient goals / interventions and prevention of hospitalizations. Review of clinical record #4 for certification period 10/23/23 to 12/21/23 revealed the following: A. The POC for Clinical Record #4 contained vita signs parameters for diastolic (bottom number) blood pressure readings below 60 mm hg. Review of a SN note dated 11/3/23 showed Patient #4 diastolic reading was 52 mm hg. There was no evidence the blood pressure reading below parameters established in the Plan of Care (POC) was reported to the physician. B. During an interview with Agency staff on 11/30/23 at 9:30 AM, Agency staff #1 verified the blood pressure was not reported to the Doctor and stated, "I spoke with the nurse who saw the patient on 11/3//23 and the nurse said the blood pressure was not reported to the Doctor." 2. Review of clinical record #8 for certification period 8/8/23 to 10/6/23 revealed the following: A. The POC for Clinical Record #8 contained vita signs parameters for diastolic (bottom number) blood pressure readings below 60 mm hg. Review of a SN note dated 8/15/23 showed Patient #8 diastolic reading was 52 mm hg. There was no evidence the blood pressure reading below parameters established in the Plan of Care (POC) was reported to the physician. B. During an interview with Agency staff on 11/30/23 at 9:30 AM, Agency staff #1 verified the blood pressure was not reported to the Doctor and stated, "I spoke with the nurse who saw the patient on 8/15/23 and the nurse said the blood pressure was not reported to the Doctor."

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 Discharge Summary was completed and sent to the Physician within 5 business days as required, after the Patient was discharged from the Agency in 1 (#7) of 8 (#1 - #8) Clinical Records records reviewed. This failed practice had the potential to place patients currently on census at risk by preventing effective and efficient coordination of care among health care team members and providers. 1. Review of Clinical Record #7 for a certification period of7/10/23 to 9/7/23 showed the Patient was discharged from the Agency on 8/1/23. A review of a document dated 8/1/23 showed the Patient was discharged from the Agency on 8/1/23. There was no evidence found in the Medical Record of a discharge summary was completed until 8/17/23, 12 business days after the Agency became aware of the Patient's discharge date. 2. In an interview on 11/30/23 at 9: 30 A.M., Agency Personnel #1 verified a discharge summary was not completed in the regulatory timely manner of 5 business days and sent to the physician.

These deficiencies were previously written under the wrong agency provider and provider number. The Agency had two provider numbers at one location but was in the process of terminating one of the provider numbers when the survey occurred. The provider number that was terminated was 047158 of July 2020. The surveyor surveyed the agency 03/24/2021 through 03/26/2021 but documented the survey under the agency to be terminated (047158) and not 047156 which is where the survey should have been documented. Agency provider number 047158 was not terminated in IQIES at the time the surveyor documented. See attached Email discussion with the Agency regarding the termination of 047158.

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: See attached CMS 2567 dated 03/26/2021 See attached CMS 2567 for deficiencies.