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

On 03/24/21 at 9:50 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 3/26/21 at 10:15 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

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 reviews and staff interview, it was determined the Agency staff did not provide care in accordance with the written Plan of Care (POC) in 1 (#3) of 7 (#1 - #7) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all patients currently on census for a of risk adverse outcomes, potential to affect the attainment of the patients individual goals and risk of hospitalizations due to unrecognized signs/symptoms of disease exacerbation. Findings: 1. A review of Clinical Record #3, revealed a document titled "Plan of Care" dated 02/28/2021 through 04/28/2021, which showed a Patient with a pertinent diagnosis of "Hypertensive heart disease with heart failure." This POC contained orders for Skilled Nursing (SN) to "Assess/monitor for weight gain, notify MD [Medical Doctor] with the following parameters: 2# [pounds] overnight, 3# in 24 hours, or 5# in 1 week." Additional orders stated: "Assess/monitor weight each visits, teach client/caregiver to keep a daily weight log and when to report weights outside of parameters, review weight log each visit, document ranges and notify MD of any outside parameters." A review of SN visit notes dated, 03/03/2021, 03/12/2021, 03/17/2021, and 03/19/2021, showed no evidence of documentation of the Patient's weights by the SN. 2. During an interview conducted on 03/19/2021 at 9:30 AM, Agency representatives were provided an opportunity to present additional information. With no additional information presented, Agency Personnel #2 stated "We didn't follow the Care Plan" confirming the Agency staff failed to provide care in accordance with the written Plan of Care for Patient #3. . . .