Every finding on record at Crossett Health Foundation

On 02/09/26 at 1:23 p.m., an entrance conference was conducted with Agency Representatives. The Agency was informed that the purpose of the visit was to conduct a Medicare Recertification Survey for compliance with CFR Part 484 Conditions of Participation for Home Health Agencies. On 02/12/26 at 11:15 a.m., an exit conference was conducted with Agency Representatives. The preliminary findings of the survey were discussed. The Agency Representatives were given an opportunity to provide further documentation.

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 review of medications during home visits, clinical record review and interview, it was determined the agency failed to ensure there were accurate medication lists in the home for 2 (#1 and #2) of 5 (#1 - #5) of clinical records reviewed. This failed practice had the potential to affect all patients on census in that the patients could possibly take or exclude medications in error. Findings follow: Review of Clinical Record #1 with a start of care date of 10/18/25 revealed a patient with a diagnosis of Pressure Ulcer stage II, Quadriplegia. On 02/10/26 at 10:00 a.m., during a home visit, the patient's medications were reconciled with the medication list. The dosages on the bottle and the medication list did not match for Alprazolam. Additionally, Oxybutynin and Hydrocodone-Acetaminophen was on the medication list and not in the home. Finally, a bottle of Tramadol was in the home but was not on the medication list. Review of Clinical Record #2 with a start of care date of 01/31/25 revealed a patient with a diagnosis of Type 2 Diabetes Mellitus, Urinary Tract Infection (UTI), and Neuropathy. On 02/10/26 at 11:00 a.m., during a home visit, the patient's medications were reconciled with the medication list. The dosages on the bottles and medication list did not match for Amiodarone, Biotin Plus Keratin, Cranberry Extract, Glimepiride, and Vitamin C. Additionally, Zinc Gluconate was not in the home. On 02/11/26, the Executive Director was asked to provide any further information regarding the discrepancies, and none was provided.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based on clinical record review and personnel interview, it was determined the agency failed to ensure a home health aide plan of care was specific and individualized for 1 of 1 (#1) Clinical Records reviewed that involved a patient utilizing home health aide services. This failed practice had the potential to affect all clients on census that receive aide services. Findings follow: Review of Clinical Record #1 with a start of care date of 10/18/25 revealed a patient with Pressure Ulcer stage II, Quadriplegia. The Home Health Certification and Plan of Care with certification period of 12/17/25 - 02/14/26 documented Home Health Aide visits 1 time a week for 8 weeks. The Aide Care Plan report did not document specifically needed care services to include shampoo, shave, oral hygiene, or nail care and how frequently these were to be provided. A Policy and Procedure provided by the Executive Director on 02/12/2026 documented, "...To assure an appropriate plan of care is developed and revised in a timely manner for each patient.... The POC (plan of care) includes...Patient specific interventions..." On 02/11/26, the Executive Director and the Registered Nurse Principal Care Manager were asked about the aide care plan and to provide additional information if able and none was provided.

On 1/09/2023 at 11:45 AM, an entrance conference was conducted with Agency Staff. The Agency was informed the purpose of the visit was to conduct a Recertification Survey for compliance with the Conditions of Participation for Home Health. On 1/12/23 at 10:30 AM, an exit conference was conducted to Agency Staff. Preliminary findings 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 it was determined the Skilled Nurse (SN), failed to include Oxygen (O2) during review of the patient's medications in 1 (#1) of 10 (#1-#10) clinical records reviewed. This failed practice by the SN posed a risk of potential harm for patient's on census receiving oxygen therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug interactions, significant side effects or significant drug interactions. Findings: Review of Clinical Record #1: A document titled "Client Medication Report" (A form used by the Agency to document the patient's medications) lists "Oxygen 3 liters." highlighted in blue. The blue highlight indicates the electronic medical record system used by The Agency did not check oxygen against all other medications for interactions. On 1/12/2023 at 10:30 AM Agency Staff were given an opportunity to provide additional information. Agency Staff #1 confirmed the O2 was not checked for interactions.

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: Based on Clinical Record Review and staff interview, it was determined the Skilled Nurse (SN) failed to follow the physicians orders in 1 (#3) of 10 (#1-#10) records reviewed by not completing the physician ordered assessment of either weighing the patient OR obtaining left calf measurement. This failure to follow physicians orders had the potential to affect all patients on census in that it is a missed opportunity to reassess, collaborate, or make changes to the POC (Plan of Care) and/or prevent complications and rehospitalizations. Review of Clinical Record #3 revealed the following: A document titled "Home Health Certification And Plan of Care" (POC) dated 10/15/2022 through 12/13/2022 showed an order for "Skilled nurse to obtain weight QSNV (every skilled nurse visit) and notify RN/MD (Registered Nurse/Medical Doctor) of weight gain or loss of 3 LBS (pounds) overnight or 5LBS over one week. If unable to weigh, measure left calf and if increased by 1 CM (centimeter) notify MD." On SN visit 10/17/2022, the weight was not documented nor was the left calf measurement documented as ordered in the POC. On SN visit 10/28/2022, the weight was not documented nor was the left calf measurement documented as ordered in the POC. During an interview with Agency Staff on 1/12/2023 at 10:30 AM, Agency Staff #1 confirmed the weight and/or calf measurements were not completed as ordered in the POC.