Every finding on record at Arkansas Homecare of Fulton, LLC

On 11/04/24 at 2:30 p.m., 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 the compliance with the Conditions of Participation for Home Health. On 11/07/24 at 10:30 a.m., an exit conference was conducted with the Agency Representatives and preliminary findings were discussed. On 11/13/24 at 10:20 a.m., Policies and Procedures were requested from the Agency, therefore, the exit date has been updated to 11/13/24.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on clinical record review, administrative document review, and staff interview, it was determined the Agency failed to make efforts to resolve problems presented by a patient's caregiver and potentially prevent a discharge for cause for 1 (#13) of 5 (#13 - #17) closed records reviewed. This failed practice had the potential to affect all patients on census that they or their caregiver presents with behaviors, or an unsafe environment becomes evident. Findings follow: Review of clinical record #13 with a start of care date of 02/24/24 revealed a patient with a diagnosis of Hypertensive Heart Disease with Heart Failure. A physician order dated 06/06/24 documented, "Patient to be desk discharged on 6/6/24 due to unsafe home environment for staff." A client coordination note report dated 05/30/24 documented a late entry note for 05/22/24 which involved a verbal argument and some physical altercation (pushing) between the patient's caregiver (male) and a female. This occurred at a workshop behind the home. A Discharge-Transfer Summary Report documented the patient was discharged to home or self-care and the reason was unsafe home environment. There was no documentation of explanation nor any interventions to resolve the problem behavior observed. On 11/06/24 at 2:45 p.m., the Executive Director was informed of the concerns regarding this discharge and asked to provide any further information. On 11/07/24 at 10:00 a.m., the Administrator provided a late entry Client Coordination Note Report dated 11/06/24 at 3:50 p.m., which documented APS (Adult Protective Service) had been contacted prior to the incident on 05/22/24 due to potential neglect as the living conditions were poor. The coordination note further documented that APS was contacted after the 05/22/24 incident was observed. There were no further interventions at that time. The family and physician were notified of the discharge. The Executive Director provided a Policy and Procedure titled "Patient Discharge/Transfer Process" documented, "...In the event a discharge for cause (i.e. disruptive, abusive, or uncooperative behavior interfering with delivery of care) is being considered, the agency will: ...b. Attempt to resolve problem(s) presented by patient's behavior or other individual's behavior in home or situation...d. Ensure the issue of concern and efforts to resolve problems is documented in the medical record. The clinical record will reflect identification of the problems encountered; assessment of the situation; communication with the physician responsible for the plan of care; a plan to resolve issues and results of the plan implementation..."

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 clinical record review, observations during home visits and staff interviews, it was determined the Agency did not include all current medications in the patient's clinical record in 7 (#1, #3, #4, #7, #8, #9, and #16) of 17 (#1-#17) clinical records reviewed. This omission had the potential to a delay identification of adverse effects such as drug interactions, significant side effects or could result in possible hospitalization. Findings follow: Review of clinical records #3, #4, #7, #8, #9, and #16 revealed there was no documentation of drug interaction, significant side effects review for the use of oxygen. Review of clinical records #1 revealed there was no documentation of drug interactions, significant side effects review for the use of medical marijuana. Review of clinical records #16 revealed there was no documentation of drug interactions, significant side effects review for the use of Vitamin B-12 and Women's daily Probiotic. The computer system utilized by the Agency had these medications highlighted in blue to indicate these have not been automatically checked for drug-drug interactions and for significant side effects. Therefore, the physician had not been contacted. On 11/07/24 at 10:00 a.m., the Executive Director confirmed these medications had not been thoroughly reviewed by manual means, documented, and physician informed as required.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation during home visits, staff interviews and review of infection control guidelines, the Skilled Nurse (SN) failed to follow accepted professional standards for infection control in 1 (#6) of 7 (#6 - #12) home visits conducted. This failed practice had the potential to place all patients with wound care at risk for complications, infection, and rehospitalization. On 11/06/2024 at 10:02 AM, a home visit was conducted to observe wound care for patient #6. Surveyor observed Skilled Nurse (SN) #1 re-using an opened bottle of saline with a date of 11/05/2024 written on the top in large letters to clean the patients wound. Surveyor asked the SN when the bottle of saline would be discarded. SN stated, “today.” The manufacturer's label on the bottle read, "...Discard after use." According to the Tyco Healthcare at http://www.lvhn.org/sites/default/files/uploads/research_education/EmergencyMedicineMedStudents/WoundCleansing.pdf, saline solutions begin to show bacteria growth within 24 hours of opening.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interview, it was determined the Agency failed to ensure documentation, including late entry documentation, of unusual events was completed timely for 1 (#13) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all patients on census in that direct caregivers would not have a full and accurate patient file to reference and use for care planning. Findings follow: Review of Clinical Record #13 with a start of care date of 02/24/24 revealed a patient with a diagnosis of Hypertensive heart disease with heart failure. A physician order dated 06/06/24 documented, "Patient to be desk discharged on 6/6/24 due to unsafe home environment for staff." This decision to discharge was based off an event dated 05/22/24. On 11/06/24 at 3:05 p.m., the Executive Director was informed of the concerns regarding this discharge and asked to provide any further information. On 11/07/24 at 10:00 a.m., the Executive Director provided a late entry Client Coordination Note Report dated 11/06/24 at 3:50 p.m. This was 5 months and 2 weeks after the original event on 05/22/24. The Executive Director provided a Policy and Procedure titled "Information Management" which documented the electronic system would be synchronized within 24 hours of visit and it shall be "...written on day of service and incorporated into medical record no less often than 14 days..."

Citation Text for Tag 0000, Regulation G406 Sperry, Cecille On June 6, 2022 at 2:15 PM, an entrance conference was conducted with Facility Representatives. The area of focus for the complaint investigation was discussed at this time. On June 10, 2022 at 10:00 AM hours, an exit conference was conducted with Facility Representatives. The Representatives were informed no deficiencies would be cited.

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 Clinical Record review and Staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications for reconciliation and medication interaction checks in 2 (#8, #12) of 17 (#1-#17) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for all patients on census by inhibiting the Nurse 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. A Review of Clinical Record #8 revealed the following: 1. A Document titled Home Health Certification And Plan of Care Certification date 12/12/2021-02/09/2022 lists a diagnosis of "Dependence on Supplemental Oxygen" 2. A Document titled Client Medication Report lists "Oxygen 3 Liters (via) Nasal Cannula as needed for shortness of breath. This is a "blue lined" entry (highlighted on the screen in a blue color) in the Electronic Medical Record charting (EMR) system used by Agency. 3. A Document titled Client Medication Report lists "Medical Marijuana, Oral". This is a "blue lined" (highlighted on the screen in a blue color) entry in the EMR. 4. Interview with Agency Staff #1 revealed "blue lined" entries in the patients medication list are not checked for interactions with other drugs in the EMR system utilized by SN. 5. When asked if either medication was checked for interactions, Agency staff #1 replied "No." A review of Clinical Record #12 revealed the following: 1. A document titled Patient Medication Profile lists no regularly scheduled medications. 2. On 5/3/2022, SN documented "Patient is supposed to wear oxygen but does not. Spouse reports SPO2 usually in the high 80's. Patient stopped taking all his medications and only takes pain medication. MD is aware" 3. An email sent to surveyor dated 06/14/2022 at 1:05 PM, shows a "snip from the H&A referral from MD visit" stating "pt has reported that he has stopped all medications other than his pain medications. Rec to patient to takes meds as prescribed." 4. SN did not obtain medication list from MD or pharmacy for patient. 5. During interview, Agency Staff #1 denied trying to obtain medication list for the patient.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Standard: Conformance with physician or allowed practitioner orders. This Standard 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 physicians orders contained in the Plan of Care (POC) for 4 ( #5, #6, #7, and #10) of 17 (#1-#17) clinical records reviewed. This failed practice had the potential of increased risk of hospitalization and obtaining treatment goals, the patient's personal goals and aspects of patient's independence. A review of Clinical Record #5 revealed the following: 1. A patient with a primary diagnosis of “Multiple Sclerosis” 2. A Document titled "Home Health Certification and Plan of Care (POC)" dated 4/08/2022 to 6/6/2022, revealed an order for Skilled Nurse (SN) to visits 3wkx1wk (3 times week for1 week), 1wkx2wk (1every 2 weeks for 1 week),1q5wx1wk (1every 5 weeks for 1 week). 3. There were 3 visits ordered but only 1 visit made for the week of April 3, 2022, through April 9, 2022. 4. There was no evidence the Agency staff followed frequency as ordered on the POC. Review of Clinical Record #6 revealed the following: 1. A primary diagnosis of “Oth Sequela Following Nontraumatic Subarachnoid Hemorrhage” 2. A Document titled "Home Health Certification and Plan of Care (POC)" dated 4/21/22 to 6/19/22, revealed an order for OT (Occupational Therapy) to evaluate effective 4/24/22 1wkx1(1time week for 1week) 3. A Document titled "Missed Visit Report" dated 5/02/2022, showed the physician was sent a faxed notification of the OT visit missed. 4. There were no evidence the Agency staff completed an OT evaluation as ordered on the POC. Review of clinical record #7 revealed the following: 1. A primary diagnosis of “Infection Following a Procedure Other Surgical Sites Int” 2. A Document titled, "Home Health Certification and Plan of Care (POC)”, dated 5/1/2022 to 6/29/2022 revealed an order for SN (Skilled Nurse) to visit 8wk1wk (8 times week for 1 week),2wkx6wk (2 times week for 6 weeks), 7wkx1wk (7 times week for 1 week), 1wkx1wk (1 time week for1 week) start 5/01/2022. 3. There were 8 visits ordered but only 5 visits were made for the week of 5/01/22 through 5/07/2022 . 4. There was no evidence the Agency staff followed frequency as ordered on the POC. Review of clinical record #10 revealed the following: 1. A Document titled, "Home Health Certification and Plan of Care (POC)”, dated 1/21/2022 to 3/21/2022 revealed an order for OT (Occupational Therapy) to evaluate/assess and develop occupational therapy POC that will be approved by the physician prior to implementation. 2. A note titled "Missed Visit Notification" shows the physician was sent a faxed notification of the OT visit missed. 3. There were no evidence the Agency staff completed an OT evaluation as ordered on the POC. 4. During an interview on 6/10/2022 at 10:00 AM, Agency Personnel were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the Agency staff’s failure to follow POC for Patient #5, #6, and 7 and #10.