Every finding on record at Conway Regional Homecare Svcs

On 12/02/24 at 10:45 a.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 and a complaint investigation survey. On 12/05/24 at 2:30 p.m., an exit conference was conducted with the Agency Representatives and preliminary findings were discussed. The complaint investigation was unsubstantiated.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review and staff interview, it was determined the agency failed to ensure a means of measuring pain control was part of the assessment tool for the skilled nurse and other professionals to utilize as part of the individualized care plan for 13 (#1- #6 and #8 - #14) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all patients on census that have pain or have pain medications ordered on an as needed basis. Findings follow: Clinical Records #1 - #6 and #8 - #14 were reviewed and noted orders for pain medications. Clinical Records #1 - #6 and #8 - #14 revealed there was no pain parameter (0-10 scale for verbal, cognitive patients or the Wong-Baker Faces pain scale utilized for non-verbal patients or for those that have cognitive decline) as part of the pain assessment. On 12/05/24 the Director of the Home Health agency was interviewed and asked to provide any further information on how the agency has a measurable assessment of current pain and response to pain interventions for their patients and none was provided.

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 observation, clinical record review, and staff interview, it was determined the agency failed to ensure a physician's order was followed as demonstrated by sterile water was utilized rather than saline during a wound care dressing change for 1 (#6) of 5 (#6 -#10) patients with wound care observed and clinical records reviewed. Findings follow: Clinical Record Review #6 with a start of care date of 04/02/21 and certification period of 11/12/23 - 01/10/25 revealed a patient with a diagnosis of Progressive Bulbar Palsy. A document titled, "Physician Order" and dated 11/27/24 documented, "SN [Skilled Nurse] to perform wound care to right low back. Remove dressing and dispose. Cleanse with normal saline and gauze, pat dry. Apply foam border dressings once daily. CG [Caregiver] to perform in absence of nurse." During a home visit on 12/03/24 at 11:59 a.m., Surveyor observed SN cleanse the wound with sterile water rather than saline as ordered. During an interview on 12/05/24 the Director of Home Health was provided with the information regarding this observation, given an opportunity to provide any further information and none was provided.

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 staff interview, it was determined the agency failed to ensure the nurse visited a patient and notify the physician with a change of condition status for 1 (#16) of 17 (#1 - #17) clinical records reviewed. This failed practice had the potential to affect all patients on census as a failure to assess a patient during a change of condition and subsequent physician notification could result in a further decline in patient condition. Findings follow: Clinical Record #16 with a start of care date of 07/08/24 and certification period of 09/06/24 - 11/01/24 revealed a patient with a diagnosis of Hemiplegia following Cerebral Infarction. A Patient Communication note dated 09/12/24 and documented by Physical Therapy Assistant (PTA) revealed, "Have attempted to schedule PT [Physical Therapy] visit x [times] 3 this week with patient refusal. Daughter stated that patient has been ill all week with diarrhea. She stated that buttocks wound has gotten worse. Requested SN [Skilled Nurse] visit and rescheduled visit to next week." A note labeled "phone call" dated 09/13/24 and documented by a Registered Nurse (RN) documented the patient has had diarrhea for several days and now has open wound to buttocks related to diarrhea. Instructions given to caregiver. There was no evidence of an in-home visit and assessment until 09/16/24. There was no evidence of physician notification. On 12/05/24 at 9:45 a.m., a Director of Home Health #2, stated it appeared the nurse who is case manager and assigned to the patient was not on call that day and decided to check in on them by phone. She further stated, "You know they get territorial; they know their patients so well and don't want to have another nurse (on-call nurse) to go see their patients."

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: Based on clinical record review and staff interview, it was determined the agency failed to ensure orders for therapy visits were set as a frequency consistent with the patient's current plan of care for 9 (#1, #3 - #7, #9, #16, and #17) of 9 clinical records reviewed that had orders for therapy. This failed practice had the potential to affect all patients on census that have orders for therapy. Findings follow: Clinical Records #1, #3 - #7, #9, #16, and #17 revealed patients with orders for therapy that were set by month rather than by week as skilled nursing, home health aide visit frequencies are managed. For example, therapy orders read 3mo1 (3 times a month for 1 month). Skilled nursing and home health aide visit frequencies are set as follows, for example, 1wk9 (1 time a week for 9 weeks). The Skilled Nursing and Home Health Aide visit frequencies are set from Sundays to Saturdays. The Therapy orders are set on 30 days' time-frame and not via calendar. The patients would not be able to know with certainty when the therapists would be expected to arrive at their home for services. On 12/04/24 and 12/05/24 Director #1 and Director #2 were informed of this finding and agreed there was a difference in how the orders were written and could confuse the patients regarding upcoming services.

On 06/21/2022 at 09:00 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 06/24/2022 at 01:00 PM 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 staff interview it was determined Agency staff Clinicians failed to notify the Physician when the updated Comprehensive Assessment indicated a change in condition in 2 (#1 and #8) of 13 (#1 - 13) Clinical Records reviewed. This deficient practice had the potential to prevent the patient from receiving appropriate care and delay attainment of personal goals Review of Patient #1Clinical Record revealed the following; A. A document titled “Home Health Certificate and Plan of Care” (POC) dated 03/3/2022 to 05/01/2022 with primary diagnosis of “Encounter for change and removal of drains”, and a Pertinent diagnosis of “malignant pleural effusion” (cancer of the lung causing fluid to accumulate on the lungs). B. A document titled “Home Health Certificate and Plan of Care” (POC) dated 03/3/2022 to 05/01/2022 C. A documentation titled” LPN Skilled Nursing Visit” dated 3/22/2022 stated, “Pt’s (Patient’s) sob (shortness of breath) has increased over the week and coughing up blood has increased.” The LPN further documented “Pt. is very weak with increased sob and coughing up more blood. Further documentation showed the LPN stated, “Friday, the pt will receive a blood transfusion at (named) hospital in (named) city. Pt’s wife stayed hm (home) from work today due to increased weakness.” D. There is no evidence Agency staff notified the physician of changes in patient condition. Review of Patient #8 Clinical Record revealed the following: A. A patient with a primary diagnosis of "Encounter for Change or Removal of Nonsurgical Wound Dressing" and a pertinent diagnosis of "Type 2 Diabetes Peripheral Angiopathy without Gangrene. B. A document titled, "Home Health Certification and Plan of Care" (POC) dated 05/25/2022 to 07/23/2022 showed orders for “S/N (skilled nurse) to notify physician of Fasting blood sugar greater than (>) 225 or less than () 300 or less than ()180 or less then () 90 or less than (<) 50. C. A document titled "Skilled Nursing Visit" dated 05/27/22 showed Random blood glucose reading of 308. D. A document titled "Skilled Nursing Visit" dated 05/30/22 showed Fasting blood glucose reading of 278 E. A document titled "Skilled Nursing Visit" dated 06/15/22 showed Blood pressure reading of 190/92. F. A document titled "Skilled Nursing Visit" dated 06/17/22 showed Random blood glucose reading of 357. G. There was no evidence the SN notified the physician of the out of parameter finding as ordered in the POC H. During an interview on 06/24//2022 at 1:00 PM, Agency Representative were provided an opportunity to present additional documentation. Agency # 1 confirmed the Agency staff did not notify the physician of changes in patient condition.in #1and #8. .

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interview, the Licensed Practical Nurse (LPN) did not communicate with the Registered Nurse (RN) information regarding patient status and health needs in 1 (#1) of 17 (#1 - #17) Clinical Records reviewed. The deficient practice identified, placed the patient at risk of adverse outcomes and hospitalization, in that the RN unaware of the patient's status and health needs. The RN did not supervise patient care and provide follow-up Review of Patient #1Clinical Record revealed the following; A. A document titled “Home Health Certificate and Plan of Care” (POC) dated 03/3/2022 to 05/01/2022 with primary diagnosis of “Encounter for change and removal of drains”, and a Pertinent diagnosis of “malignant pleural effusion” (cancer of the lung causing fluid to accumulate on the lungs). B. A document titled “Home Health Certificate and Plan of Care” (POC) dated 03/3/2022 to 05/01/2022 C. A documentation titled” LPN Skilled Nursing Visit” dated 3/22/2022 stated, “Pt’s (Patient’s) sob (shortness of breath) has increased over the week and coughing up blood has increased.” The LPN further documented “Pt. is very weak with increased sob and coughing up more blood. Further documentation showed the LPN stated, “Friday, the pt will receive a blood transfusion at (named) hospital in (named) city. Pt’s wife stayed hm (home) from work today due to increased weakness.” D. The RN was unaware of patient's status and health needs. The RN didn't supervise the patient's care and provide follow up. E. During an interview on 7/24/22 at 1:00 PM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 confirmed the RN failed to supervise patient's care and provide follow up regarding patient status and health needs.