Every finding on record at Kah Development 4, LLC

On 10/04/2022 at 3:30 PM, an entrance conference was conducted with Agency representatives. 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 10/06/2022 at 4:00 PM, an exit conference was conducted. 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 and Staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications for reconciliation and medication interaction checks in 2 (#5,#10) of 13 (#1-#13) 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 Physicians ability to make informed decisions regarding the patent's medication regiment related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. Review of Clinical Record #5 revealed the following: A. A Document titled "Client Medication Report" (a form the Agency uses to document medications the patient is taking) and dated 1/7/2022 listed Oxygen. B. The Clinical Record showed no evidence Oxygen was reviewed with all other medications. C. A document titled, "Coordination Note" and dated 10/05/2022 showed the Agency had completed a drug review, including Oxygen, the day after the survey had started. The Registered Nurse documented, "Oxygen was checked against the clients medications to assure there were no severe interactions." 2. Review of Clinical Record #10 revealed the following: A. A Document titled "Client Medication Report" (a form the Agency uses to document medications the patient is taking) and dated 8/22/2022 listed Oxygen. B. The Clinical Record showed no evidence Oxygen was reviewed with all other medications. C. A document titled, "Coordination Note" and dated 10/05/2022 showed the Agency had completed a drug review, including Oxygen, the day after the survey had started. The Registered Nurse documented, "Oxygen was checked against the clients medications to assure there were no severe 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 Patient's Plan of Care for patient specific interventions regarding monitoring the patient's weight each visit in 1 (#2) of 13 (#1-#13) clinical records reviewed. This deficient practice has the potential to prevent the Physician and SN from evaluating the patient's improvement or decline and prevented the physician from determining the needed care. A Review of Clinical Record #2 revealed the following: A document titled "Home Health Certification and Plan of Care" dated 08/09/2022 through 10/07/2022 showed an order for the SN to report weight gain of 2-3 lbs./day (pounds per day) or 5 lbs. in one week. The Clinical Record showed no evidence the SN monitored the patient's weight as ordered in the patient's Plan of Care. During a home visit conducted on 10/06/2022, the patient's caregiver reported the patient doesn't have scales in her home.

Revisions communicated to patient and MDs CFR(s): 484.60(c)(3)(i) (i) Any revision to the plan of care due to a change in patient health status must be communicated to the patient, representative (if any), caregiver, and all physicians or allowed practitioner's issuing orders for the HHA plan of care. This ELEMENT is not met as evidenced by: Based on Clinical Review and staff interview, it was determined the Agency staff did not communicate with the physician about the Agency's inability to follow the patient's Plan of Care in 1 (#2) of 13 (#1-#13) clinical records reviewed. This lack of communication had the potential to affect all patients on census, in that, all patients must have patient specific orders for assessment and monitoring of the patient's condition. This ELEMENT is NOT MET as evidenced by: Clinical Record #2 revealed the following: A document titled "Home Health Certification and Plan of Care" dated 08/09/2022 through 10/07/2022 showed an order to report weight gain of 2-3 lbs./day (pounds per day) or 5 lbs. in one week. On a form titled, "Coordination Note" and dated 09/21/2022, the Skilled Nurse documented, a request for scales to be taken to the patient's home as the patient did not have one. During a telephone interview on 10/06/2022, the patient's caregiver reported the patient doesn't have scales in her home. During an interview with Agency Staff #1 on 10/06/2022 at 4:00 PM, Agency Staff #1 confirmed the Agency had not supplied scales for the patient to be weighted and had the scales on back order from their supplier for several months. The Clinical Record showed no documentation the patient's physician was contacted regarding the Agencies inability to weigh the patient thus inhibiting the physician from possibly revising the patient's plan of care.