Every finding on record at Kah Development 4, LLC

On 02/26/2024 at 1:50 PM 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 CFR Part 484 Conditions of Participation for Home Health Agencies. On 02/29/2024 at 11:15 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 interview, it was determined the Skilled Nurse (SN) failed to include Oxygen (O2), during review of patient medications in 1 of 10 clinical records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy 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. Review of clinical record # 2 revealed a document titled "client Medication Report" listed Oxygen 2 liters continuous for shortness of breath. The Electronic Medical Record (EMR) system the Agency uses shows Oxygen as highlighted in blue indicating it was not checked via the EMR. Agency Representatives were given an opportunity to provide additional documentation. On 02/29/24 at 10:05 AM, Agency Representative #2 confirmed the lack of medication review for Oxygen and stated, "No. It was missed."

On 05/25/21 at 11:25 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 05/28/21 at 10:00 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: . Based on Clinical Record reviews and staff interview, it was determined the Agency staff did not provide care in accordance with the written Plan of Care (POC) in 1 (#7) of 10 (#1 - #10) Clinical Records reviewed. This failed practice had the potential to affect the quality of care received by all 79 patients currently on census for a risk of adverse outcomes, potential to affect the attainment of the patients individual goals and risk of hospitalizations. Findings: 1. Review of Clinical Record #7, revealed a document titled "Certification and Plan of Care" dated 04/25/2021 through 06/23/2021, which showed a Patient with a diagnosis of "Encounter for Fitting and Adjustment of Urinary Device". This POC contained orders for Skilled Nursing (SN) to "insert/change /maintain indwelling catheter, 16 FR [French] 10 Ml [Milliter] balloon, change monthly and PRN [as needed] dislodgement/stoppage using sterile technique...". 2. Review of an Agency document titled "Visit Note Report" dated 05/06/2021 revealed SN documentation as follows: ""Inserted silicone catheter/16 FR/30 Ml Balloon....." 3. During an interview conducted on 05/28/2021 at 9:00 AM, Agency representatives were provided an opportunity to present additional information. Agency Personnel #1 presented a document with "order #4363710", dated 05/27/2021. Agency Personnel #1 stated "this order updates the POC to use 16 FR 30 ML balloon." Surveyor questioned Agency Personnel #1 if the clarification order would have been written had the Surveyor not identified the order was not followed by SN on 05/06/2021 visit. Agency Personnel #1 stated "Probably not", confirming the SN failed to provide care in accordance with the written POC.