Every finding on record at Spring River Home Health Agency, Inc.

On 05/12/2025 at 11:00 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 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 05/16/2025 at 9:15 AM, an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed.

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 Staff failed to ensure all patients (#1-#13) had an individualized plan of care that identified the patient-specific measurable outcomes and goals which were established, periodically reviewed, and signed by the patients physician or practitioner, This had the potential to affect all patients on census in that a clinician should have the ability to measure and document any pain the patient may have had prior to treatment, during the delivery of care and treatment, after treatment or as an unusual symptom. Without the ability to measure and reassess or remeasure the patient's pain, there is no way a physician or practitioner can make an informed decision to intervene with changes to Plan of Care. It was determined during record review that records #1-#6 lacked pain parameters. Skilled Nurse was asking about pain on each visit and documenting it in the patients EMR (electronic Medical Record). There was no pain parameters set for the patients, even those with a potential for needing a focused pain assessment and intervention for pain secondary to wounds or treatments. On 05/15/2025 at 2:05 PM, Agency Representatives were asked for the policy for regarding pain parameters. Per Agency Representative #1, "There isn't one."

On 09/12/2022 at 1:30 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 the Conditions of Participation for Home Health. On 09/15/2022 at 10:30 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, it was determined the Skilled Nurse (SN) failed to include all medications during the review of the patients medications in 4 (#1, #2, #3, and #6) of 14 (#1 - #14) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census 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. 1. Review of Clinical Record #1 revealed the following: A. Document titled "Medication Profile which showed "Oxygen (O2) 2L (Liters) via NC (nasal cannula) to wear at all times." The O2 was highlighted in the color blue indicating the O2 was not included in the review of all the medications. There was no evidence that the SN reviewed the O2 via other means. During an interview on 9/15/22 at 10:00 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 and #2 confirmed the SN did not include O2 during a review of medications for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 2. Review of Clinical Record #2 revealed the following: A. Document titled "Home Health Certification and Plan of Care (POC) dated 7/15/22 to 9/12/22 containing a contradictive order as follows: Treatments for "Fortaz (a medication used for treating infections) 2 GM (grams) 4 ea. (each) 8 grams continuous IV (intravenously) over 24 hours. Another order with same POC showed "Fortaz 8mg (milligrams)over 24 hours for 42 days." Another order in this POC showed "Fortaz 6 gm continuous." B. Review of SN visit notes shows documentation that the SN administered Fortaz 6gm over 24 hours. C. During an interview on 9/15/22 at 10:00 a.m. Agency Representatives were provided an opportunity to present additional documentation. Agency Personnel #3 presented a pharmacy order received by the Agency containing orders for "Fortaz 6g (grams) continuous." Agency Personnel #3 confirmed the order for Fortaz dosage of 8 gms and 8 mg in the POC was incorrect, and that the SN failed to review the Fortaz in the medication review for dosage accuracy. 3. Review of Clinical Record #3 revealed the following: A. Document titled " Home Health and Plan of Care" which included orders for "O2 2 - 3 L NC intermittent use." B. Document titled "Medication Profile" (documented utilized by the Agency to document all medications the Client is currently prescribed). There was no evidence O2 was listed on the Medication Profile and no evidence the SN reviewed O2 for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 4. Review of Clinical Record #6 revealed the following: A. Document titled " Home Health and Plan of Care" which showed documentation that the "Patient is tolerating wearing O2 at HS (bedtime) and PRN (as needed) well." B. Document titled "Medication Profile" showed no evidence O2 was listed on the Medication Profile and no evidence the SN reviewed O2 for potential adverse effects, drug reactions, significant side effects or significant drug interactions. C. During an interview on 9/15/22 at 10:00 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 and #2 confirmed the Agency staff did not include all medications the patients were currently using during a review of medications. Agency Personnel #2 stated "Oxygen was not on the medications list," and the SN failed to review the O2 for potential adverse effects, drug reactions, significant side effects or significant drug interactions. .