Every finding on record at Baptist Health Home Health - Heber Springs

On 5/06/2024 at 9:20 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 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 5/09/2024 at 11:40 AM, an exit conference was conducted with Agency Representatives. Preliminary findings were discussed. On 5/14/2024 at 7:50 AM, additional information was requested.

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on the pre-survey review of the Agency's reports, it was determined the agency failed to transmit all comprehensive assessments within the 30 day timeframe as required by CMS Conditions of Participation (CoP). This failed practice, if not corrected, could result in more late records submissions. A review of the HHA Error Summary report showed there were 17 comprehensive records that had been submitted past 30 days after completion of the record as of 4/30/2024.

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, standard reporting parameters used by the Agency when the physician has not ordered specific patient parameters, and Agency staff interview it was determined the Physical Therapist (PT) failed to alert the Physician of relevant assessment findings which may have necessitated an alteration in the Plan of Care (POC) in 1(#10) of 10 (#1 - #10) 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. 1. Review of Clinical Record #10, revealed a Patient with a Start of Care of 04/06/2024. Review of a document titled, "PT initial Evaluation," dated 04/10/2024, revealed the PT documented the Patient with a blood pressure reading of 186/94 at 11:25 AM and a second reading of 178/92 at 11:35 AM. A review of a document titled “Baptist Health Home Health Network Parameters for Reporting” showed “Measurements that fall outside of established parameters are reported to physicians and approved non-physician practitioners.” The Parameters for Reporting blood pressure readings were less than 100/50 or greater than 160/90. There was no evidence in the clinical record that the PT had notified the Physician of the blood pressure reading that were outside the parameters for reporting. 2. During an interview on 05/09/2024 at 10:30 AM, Agency Personnel #1, verified the Physician was not notified of the change in condition evidenced in the PT assessment.

Plan of care revisions must be communicated CFR(s): 484.60(c)(3) Revisions to the plan of care must be communicated as follows: This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interviews, it was determined Occupational Therapy revised treatment in two (#2, #7) of 10 (#1-#10) clinical records reviewed. In each record, the OT (Occupational Therapist) discontinued service to the patient without evidence of notifying the ordering physician. This failed practice, if left uncorrected, had the potential to affect all patients on service receiving OT in that the lack of communication to the physician may inhibit an accurate clinical picture of the patient's recovery, rehabilitation or improvements thus impacting the overall plan of care and course of home health. Clinical Record #2 revealed Clinical Record #2 revealed an OT (Occupational Therapy) evaluation on 4/15/24 at 9:06 AM, with subsequent visits ordered for two visits per week for two weeks. On the next OT visit, 4/19/24 at 10:00 AM, OT documented "....is discharged from OT services with goals met." There was no evidence of OT communicating with the physician about the patients goals being met nor was there an order written to discontinue the OT services. Clinical Record #7 revealed an OT evaluation on 1/22/24 at 9:30 AM with physicians order for patient to receive OT 3three times weekly for four weeks. Documentation form the OT on 1/29/24 states "Pt (patient) is discharged from OT services with goals met." There was no evidence of OT communicating with the physician about the discontinuation of services nor was an order received from the physician to stop Occupational Therapy. Agency staff were offered the opportunity to provide additional information. Agency Representative #1 confirmed there were no discontinuation orders or communication concerning the revision of plans of care.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: The HHA must ensure a written visit schedule including frequencies for all HHA personnel and persons acting on behalf of the Agency is provided to the patient based on the most current plan of care. Based on clinical record review, staff interview and patient schedule review, it was determined the Agency failed to provide the patient a written schedule in three (#3 & #7-#8) of 10 (#1-#10) of clinical records reviewed. This deficient practice, has the potential to affect all patients on census in that a lack of or nonadherence to a visit schedule may directly impact patients health status and possible rehospitalization. Clinical record #3 revealed the following: A document titled "Home Health Plan of Care" effective from 4/30/24 through 6/28/24 showed a Skilled Nursing frequency as "2 visits every 20 days for 20 days" with effective dates between 6/9/24 to 6/28/24 Clinical Record #7 revealed: A document titled "Home Health Plan of Care" effective from 1/18/24 through 3/17/24 showed a Physical Therapy frequency of "7 visits every 30 days for 30 days." Clinical Record #8 revealed the following: A document titled "Home Health Plan of Care" effective from 2/16/24 through 4/15/24 showed a HHA (Home Health Aide) frequency as "1 visit every 16 days for 16 days." and a Skilled Nursing frequency as "4 visits every 30 days for 30 days." effective 3/17/24 to 4/15/24. Agency Representative was asked to clarify the visit frequencies as written above. On 5/8/24 at 10:50 AM, Staff #1 stated, "The therapists have been writing their frequencies this way for a very long time due to our old system [previous electronic medical record program used]. We've (the Agency Administration) been trying to get them into the habit of writing the frequencies differently."

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on Clinical Record Review and Medication Regimen review, it was determined the Agency failed to provide complete medication instructions for one (#1) of 10 (#1-#10) Clinical Records reviewed. This failed practice, had the potential to affect all patients on census in that incomplete dosage information may result in serious adverse side effects, a delay in getting emergency treatment, and potential death. Findings as follows: Clinical Record #1 revealed a document titled "Out patient Medications on the Plan of Care" listed medication Nitroglycerin 0.4 mg SL (sublingual) with instructions to "place 1 tablet under the tongue every 5 minutes as needed for chest pain." This instruction as written, is incomplete. The standard and common dosing instructions for Nitroglycerin and according to Drugs.com, include the medication is only to be administered for a limited dosage of every five minutes for 15 minutes or three doses. If chest pain is not relieved, then the patient or caregiver needs to seek emergent care as the patient may be experiencing a Myocardial Infarction (heart attack). With continued use, past the three doses/15 minute standard, the patient may experience Headache, unusual weakness or fatigue, shortness of breath, nausea, vomiting, rapid heartbeat, blue skin or lips, increased pressure around the brain—severe headache, blurry vision, change in vision, nausea, vomiting, low blood pressure—dizziness, feeling faint or lightheaded, blurry vision, slow heartbeat—dizziness, feeling faint or lightheaded, confusion, trouble breathing, unusual weakness or fatigue. According to NIH.gov, there is no known antidote for Nitroglycerin overdose.

A Desktop Survey was completed on 10/27/2021. The Plan of Correction is accepted. The State Recommends no further action.

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: All deficiencies have been corrected with an acceptable Plan of Correction. The State recommends no further action.

. On 09/21/21 at 11:03 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 09/24/21 at 9:55 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

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, the Agency did not ensure a Registered Nurse (RN) conducted a timely and accurate Drug Regimen Review (DRR - review of medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions) to include all current and added medication the patient was taking in 1 (#2) of 10 (#1 - #10) clinical records reviewed. This deficient practice posed a risk of potential harm for all recertified therapy only patients by inhibiting the Skilled Nurse (SN) and Physician's ability to make informed decisions regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Findings follow: 1. Review of clinical record #2 with a certification period of 08/15/2021 to 10/13/2021 showed the DRR was completed by the Speech Therapist (ST) on 08/12/2021 during the Comprehensive Assessment for the patient's Re-Certification (Recert) period. There was no documentation of an RN conducting a DRR as of the date of this review. 2. During an interview on 09/23/2021 at 2:00 PM, Agency Personnel #1 was asked to provide any additional documentation to demonstrate the DRR was completed timely and accurately by an RN. Agency Personal #1 stated " ST documented no changes in patient medication and a Nurse did not review the medications. Agency Personal #1 stated "SLP reviewed the meds at recert and there was no changes since the prior plan of care" With no additional documentation provided, Personnel #1 confirmed the Agency did not ensure an RN conducted the DRR as required.