Every finding on record at Arc Therapy Services, LLC

Observed in HR File Review. In 1 of 1 HR files reviewed with Volunteer, During HR# 1's HR file reviewed it was noted the organization had not ensured it provided ongoing emergency management training when there was a significant revision to the emergency operations plan, policies, and/or procedures. For example: An Emergency Management plan revision was dated approximately 3 months prior to the surveyor review of the record. However, review of HR# 1’s HR files and the Emergency Management plan in-service sign-in sheet revealed no documentation HR# 1 had completed the education/training. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 1 of 19 patient records reviewed, during RRNHV# 4's patient record review it was noted the organization had not ensured staff followed organization policy Comprehensive Assessment No.H:2-050. and Ongoing Comprehensive Assessment H:2-051 that included assessing the skin. For example: review of RRNHV# 4's patient record revealed documentation approximately four days after the start of care that the RN removed a single suture from RRNHV# 4's middle back. However, review of the RN start of care comprehensive assessment revealed documentation under Integumentary no skin issues and subsequent Skilled Nurse visit revealed documentation of no skin issues with no evidence a complete skin assessment was completed on RRNHV# 4, as there was a suture in the middle of the back from a procedure performed prior to admission to hospice. This was reviewed, discussed, and validated with the Alternate Administrator. Observed in Patient Home. In 1 of 2 home visits conducted with RN, During RRHV# 4's home observation it was noted the organization had not ensured staff followed organization policy Ongoing Comprehensive Assessment H:2-051 that included assessing skin integrity. For example: during RRHV# 4's home observation the registered nurse (RN) did not assess RRHV# 4's skin integrity. This was discussed with the RN that shared it was not always assessed at each visit. Review of RRHV# 4's patient record revealed RRHV# 4 had a terminal diagnosis of Protein Calorie Malnutrition and a history of a coccyx pressure ulcer. This was observed, discussed, and validated with the Alternate Administrator. Observed in Record Review. In 1 of 3 patient records reviewed with wound care, During RRHV# 2's patient record review it was noted the organization had not ensured staff followed organization procedure Home Health and Hospice Wound Care that included assessing the wound bed and surrounding area, wound measurement, and amount and type of drainage present, if any. For example: Review of RRHV# 2's patient record revealed a as needed Skilled Nurse visit note indicating new pressure sores to left and right buttock and two additional Skilled Nurse visit notes with documentation that patient had a right buttock pressure sore with no documentation of size, drainage, or wound bed. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 1 of 19 patient records reviewed, During RRHV# 2's patient record review it was noted the organization had not ensured an initial bereavement assessment was completed. For example: review of RRHV# 2's patient record revealed RRHV# 2 had been discharged with a new election of benefit seven days after discharge. Further review of RRHV# 2's patient record revealed no documentation of an initial bereavement assessment approximately 75 days after the new election of benefit. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 1 of 1 patient records reviewed with Volunteer services, during RRHV# 4's patient record review it was noted the organization had not ensured the update to the comprehensive assessment included information about the patient's progress toward desired outcomes and the patient's response to volunteer care. For example: review of RRHV# 4's plan of care and subsequent updates to the plan of care/Interdisciplinary (IDG) meeting notes revealed volunteer frequency of 1-3 visit a month for companionship. Further review of the updates to the plan of care/IDG meeting notes revealed no documentation of the discussion at the IDG meetings that the volunteer visited or progress toward desired outcomes. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 2 of 19 patient records reviewed, during RRNHV# 1 and RRNHV# 4's patient records review it was noted the organization had not ensured the patient record was accurately documented. For example: review of RRNHV# 1's patient record revealed a Skilled Nurse (SN) visit note with documentation that RRNHV# 1 had fallen during the night before the nurse visit. Further review of the SN visit note revealed documentation No under has patient fallen since last visit. Review of RRNHV# 4's patient record revealed a Skilled Nurse (SN) Supervisory visit note with supervisory documentation of the hospice aide. However, further review of RRNHV# 4's patient record revealed the first hospice aide visit was two days after the SN Supervisory visit note. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 5 of 19 patient records reviewed, During RRHV# 1, RRHV# 2, RRHV# 3, RRHV# 4, and RRNHV# 3's's patient records review it was noted the organization had not ensured the plan of care was based on the patient's goals and the time frames, settings, and services required to meet those goals. For example: review of RRHV# 1 and RRHV# 2's plans of care revealed a goal that the Chaplain would visit with the patient in the months of September and October. Review of RRHV# 3's plan of care revealed a goal that the chaplain would visit the months of October and November. Review of RRHV# 3's patient record revealed RRHV# 3's election of benefit (EOB) was approximately 72 days prior to the surveyor review of the patient record. Further review of RRHV# 3's plan of care and subsequent updates to the plan of care revealed the goal to admit to hospice [EOB date]. Review of RRHV# 4's patient record revealed RRHV# 4 was admitted with an indwelling urinary catheter for urinary retention. However, review of RRHV# 4's plan of care revealed no goal for the indwelling urinary catheter. Further review of RRHV# 4's plan of care revealed Volunteer for companionship with a frequency of 1-3 visits a months. Review of RRHV# 4's plan of care revealed no documented goal for the volunteer. Review of RRNHV# 3's RN start of care comprehensive assessment that revealed RRNHV# 3 had a diagnosis of Diabetes Mellitus (DM) Type 2, taking 25 units of Lantus insulin and Metformin. Further review of the RN start of care comprehensive assessment revealed RRNHV# 3 was checking blood sugars daily that averaged 90-160. However, review of RRNHV# 3's plan of care revealed no goals for DM. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 5 of 19 patient records reviewed, During RRHV# 2, RRHV# 4, RRNHV# 2, RRNHV# 3, and RRNHV# 4's patient records review it was noted the organization had not ensured it planed the patient's care to include medications and treatments necessary to meet the patient's needs. For example: review of RRHV# 2's patient record revealed documentation in the Skilled Nursing visit notes that Calmoseptine was to be applied after every toileting. However, review of RRHV# 2's plan of care and updates to plan of care revealed no documentation of Calmoseptine or that it was to be applied after every toileting. Further review of RRHV# 2's patient record revealed documentation that a left elbow skin tear had resolved approximately 26 days prior to the surveyor review of the record. However, review of the plan of care and updates to the plan of care revealed wound care order to be performed twice weekly. Review of RRHV# 4's patient record revealed RRHV# 4 was admitted with an indwelling urinary catheter for urinary retention and was removed approximately 12 days after the start of care. However, review of the plan of care revealed no documentation of an indwelling urinary catheter or removal of the catheter. Further review of RRHV# 4's patient record revealed documentation that calmoseptine was to be applied to a reddened area on the coccyx. Further review of RRHV# 4's plan of care revealed no documentation of calmoseptine. Review of RRNHV# 2's patient record revealed RRNHV# 2 had an indwelling urinary catheter. However, review of the plan of care revealed no documentation of an indwelling urinary catheter. Review of RRNHV# 3's RN start of care comprehensive assessment revealed documentation that RRNHV# 3 had a diagnosis of Diabetes Mellitus (DM) Type 2 and was taking 25 units Lantus insulin and Metformin. Further review of the RN start of care comprehensive assessment revealed RRNHV# 3 was checking blood sugar daily. However, review of RRNHV# 3's plan of care revealed no documentation of blood sugar checks. Review of RRNHV# 4's patient record revealed documentation the RN removed a single suture located on the middle of RRNHV# 4's back. Review of the plan of care and updates to the plan of care revealed no documentation of sutures or sutures to be removed. This was was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Patient Home. In 1 of 2 Home visits conducted with wound care, During RRHV# 2's home observation it was noted the organization had not ensured staff provided wound care in accordance with the plan of care that included to clean the coccyx wound with wound cleanser and apply an Allevyn foam dressing. For example: during RRHV# 2's home observation the registered nurse (RN) was observed cleaning RRHV# 2's coccyx wound with wound cleanser, applied Calmoseptine to the wound bed, and covered with a foam dressing. This was observed, reviewed, discussed, and validated with the Alternate Administrator.

Observed in Patient Home. In 1 of 4 home visits conducted, During RRHV# 2's home observation it was noted the organization had not ensured staff followed organizational policy Hand Hygiene No.H:2-136, that included performing hand hygiene before and after removing gloves, policy and policy Dress and Appearance H:3-025, that included fingernails should be neat, clean and well groomed and nail length should not extend beyond 1/4 over the finger. In addition, the organization had not ensured staff followed the Center for Disease Control (CDC) Hand Hygiene that included drying hands after washing hands. For example: During RRHV# 2's home observation the registered nurse (RN) was observed washing hand with soap and water and shaking water off the hands without drying with a paper towel. The RN was observed cleaning the wound with gloves then removed gloves and without performing hand hygiene put on new gloves. In addition, the RN had multiple glove changes without performing hand hygiene before or after glove change. The RN was observed reaching in to the supply bag without performing hand hygiene prior to entering, and the bag, and the RN was observed with artificial nails that were approximately 1/2 inch long over the nail with one missing artificial nail from the right thumb. This was observed, discussed, and validated with the RN and Alternate Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed with Volunteer, During HR# 1's HR file review it was noted the organization had not ensured patient care Volunteers were provided infection control/blood borne pathogens education/training annually per OSHA requirements. For example: review of HR# 1/Volunteer's HR file revealed HR# 1/s date of hire approximately 3 years and 8 months prior to the surveyor review of the HR file. Further review of HR# 1's HR file revealed no evidence of annual infection control/blood borne pathogens education. Leadership review additional volunteer HR files and validated no evidence of annual infection control/blood borne pathogen education was provided.This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 1 of 19 patient records reviewed, during RRNHV# 9's patient record review it was noted the organization had not ensure the Chaplain completed a Spiritual comprehensive assessment. For example: review of the Chaplain Initial Spiritual Assessment revealed documentation that RRNHV# 9 had requested a Chaplain. Further review of the Spiritual Assessment revealed documentation that the Chaplain left a message on RRNHV# 9's Mother's phone to set up a time to complete the assessment with RRNHV# 9. Further review of RRNHV# 9's patient record revealed documentation of a phone call approximately 12 days after the election of benefit with documentation a message was left for a return call. Further review of RRNHV# 9's patient record revealed no documentation of a Spiritual assessment or phone call by the Chaplain. Review of RRNHV# 9's plan of care revealed a Chaplain frequency of one time a month to provide spiritual care and presence. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 2 of 7 patient records reviewed with Hospice Aide, during RRHV# 2's patient records review it was noted the organization had not ensured the hospice aide written patient care instructions were complete and on the plan of care. For example: review of RRHV# 2's patient record revealed an elbow dressing and a buttock dressing. However, review of the hospice aide written patient care instructions revealed no documentation regarding the wound dressing or what to do if the dressing got wet during showers. Review of RRHV# 4's hospice aide written patient care instructions revealed calmoseptine/barrier cream to be applied after toileting. However, review of RRHV# 4's plan of care revealed no documentation of calmoseptine/barrier cream. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in HR File Review. In 1 of 1 HR files reviewed with Volunteer, During HR# 1's HR file review it was noted the organization had not ensured staff competence was assessed and documented once every three years in accordance with law and regulation. For example: review of HR# 1/Volunteer's HR file revealed HR# 1's date of hire approximately 3 years and 8 months prior to the surveyor review of the record. Further review of HR# 1's HR file revealed no evidence of a competency assessment since the initial competency over three years ago. Leadership reviewed additional volunteer HR files and validated no documentation of ongoing competency assessments present. This was reviewed, discussed, and validated with the Alternate Administrator. Observed in HR File Review. In 1 of 8 HR files reviewed, During HR# 2's HR file review it was noted the organization had not ensured staff was competent to perform their responsibilities. For example: Review of HR# 2/Chaplain, Volunteer Coordinator and Bereavement Coordinator's HR file revealed HR# 2 had been assigned the responsibilities of Volunteer Coordinator and Bereavement Coordinator positions in 2024.. Further review of HR# 2's HR file revealed no evidence of an initial competence assessment for the Volunteer Coordinator or the Bereavement Coordinator. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Patient Home. In 2 of 2 Home visits conducted with medication reconciliation, during RRHV# 2 and RRHV# 4's home observations it was noted the organization had not ensured the patient records contained information that reflected the patient's care, treatment, or services. For example: during RRHV# 2's home observation the registered nurse (RN) was observed completing a medication reconciliation with the Assisted Living Facility (ALF) medication administration record (MAR) that revealed the ALF MAR had Metoclopramide 5mg daily that started approximately 20 days prior to the home observation and Hyland Leg Cramp 2 tablets every four hours as needed for leg cramps. However, there was no documentation of these medications on the RRHV# 2's medication profile. During RRHV# 4's home observation it was noted RRHV# 4 was taking Tylenol 325 mg two tablets twice a day and the RN educated RRHV# 4 that the order was for three times a day if RRHV# 4 had additional pain. However, review of RRHV# 4's medication profile revealed no documentation of Tylenol. This was observed, discussed, and validated with the RN and Alternate Administrator.

Observed in Record Review. In 1 of 3 patient records reviewed with live discharge, during RRHV# 2's patient record review it was noted the organization had not ensured discharge information about the care, treatment, or services provide to the patient was given to the other service providers who will provide patient with care, treatment, or services. For example: review of RRHV# 2's patient record revealed an administrative discharge from the hospice for approximately seven days. Further review of RRHV# 2's patient record revealed no documentation that discharge information was given to the Assisted Living Facility or the community primary provider. This was reviewed, discussed, and validated with the Alternate Administrator.

Observed in Record Review. In 1 of 8 active patient records reviewed, During HV# 1's patient record review it was noted the organization had not ensured staff followed the organization's wound assessment policy that included weekly measurements. For example: review of HV# 1's patient record revealed a RN (registered nurse) recertification comprehensive assessment dated approximately 57 days prior to the surveyor review of the record with documentation that HV# 1 had a pressure ulcer stage 2 on the coccyx. Further review of the RN recertification comprehensive assessment revealed no wound assessment documentation. Review of the update to the plan of care/ IDG dated approximately 49 days prior to the surveyor review of the record revealed documentation of a new stage 2-3 pressure ulcer on the coccyx. Review of HV# 1's patient record revealed a wound measurement approximately 50 days after the RN recertification comprehensive assessment. This was reviewed, discussed, and validated with the Clinical Services Manager (CSM).

Observed in Record Review. In 8 of 8 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 1, RR# 2, RR# 3, RR# 4, and RR# 5's patient records review it was noted the organization had not ensured the written plan of care was based on the time frames, settings, and services required to meet those goals. For example: review of HV# 1, HV# 3, RR# 1, RR# 2, RR# 4, and RR# 5’s plans of care and subsequent updates to the plan of care/IDG revealed a scheduled frequency for both the MSW and the Chaplain with no documented goals. Review of HV# 1's recertification plan of care and subsequent updates to the plan of care/IDG revealed a goal for integumentary that patient will maintain skin integrity thru end of life. However, review of HV# 1's patient record revealed HV# 1 had a stage 2-3 pressure ulcer at time of the recertification. Review of HV# 2's recertification plan of care and subsequent updates to the plan of care/IDG revealed a goal Patient will not lose 3lbs in the next 30 day [dated approximately 21 days prior to the surveyor review of the record]. However, further review of HV# 2's patient record revealed documentation that HV# 2 had dysphagia and did not want an altered diet due to risk of aspiration and wanted comfort measures only. Review of RR# 4's recertification plan of care and five subsequent updates to the plan of care/IDG revealed the goal “5 nights Respite stay [date 49 days prior to the recertification plan of care]. Review of RR# 3’s plan of care revealed a scheduled frequency for MSW with no MSW goals. This was discussed and validated with Leadership.

Observed in Record Review. During RR# 1's patient record review it was noted the organization had not ensured the plan of care included interventions to manage pain and symptoms. For example: review of RR# 1's patient record revealed RR# 1 was admitted 104 days prior to the surveyor review of the record. Review of RR# 1's registered nurse (RN) comprehensive assessment revealed RR# 1 had an Aspira tube for paracentesis. Review of RR# 1's Skilled Nurse (SN) visits note dated 102 days prior to the surveyor review of the record revealed documentation that the entry site of the Aspira tube was bleeding and the dressing was saturated and a dressing change was completed. Further review of the SN visit notes revealed 27 SN visits notes with documentation the Aspira tube was drained. Review of the start of care plan of care, subsequent updates to the plan of care/IDG, the recertification plan of care, and subsequent update to the plan of care/IDG revealed no interventions for the Aspira drain or the dressing to the Aspira drain.

Observed in Regulatory Review. During HV# 3, RR# 1, and RR# 2's patient records review it was noted the organization had not ensured the plan of care addressed all issues identified in the comprehensive assessment. For example: review of HV# 3's patient record revealed HV# 3's start of care was 69 days prior to the surveyor review of the record. Review of the initial Medical Social Worker assessment revealed documentation that family needed assistance with funeral arrangements. Review of the plan of care and subsequent updates to the plan of care/IDG revealed no documentation that funeral arrangements were needed. Review of RR# 1's patient record revealed RR# 1's start of care was 104 days prior to the surveyor review of the record. Review of the initial MSW assessment revealed documentation that family needed assistance with funeral arrangements. Review of the plan of care, subsequent updates to plan care/IDG, and recertification plan of care revealed no documentation that funeral arrangements were needed. Review of RR# 2's patient record revealed RR# 2's start of care was 64 days prior to the surveyor review of the record. Review of the initial MSW assessment revealed documentation that family needed assistance with funeral arrangements. Review of the plan of care and subsequent updates to the plan of care/IDG. revealed no documentation that funeral arrangements were needed. This was reviewed, discussed, and validated with the Administrator, Director of Clinical Services, and Clinical Services Manager.

Observed in Record Review. In 4 of 8 active patient records reviewed, During HV# 1's patient record review it was noted the organization had not ensured the plan of care included services needed for the palliation and management of the terminal illness and related conditions, including medication and treatment necessary to meet the patient's needs . For example: review of HV# 1's patient record revealed a RN (registered nurse) recertification comprehensive assessment dated approximately 57 days prior to the surveyor review of the record with documentation that HV# 1 had a pressure ulcer stage 2 on the coccyx. Review of the recertification plan of care and update to the plan of care/IDG revealed wound care dressing orders dated approximately 8 days prior to the surveyor review of the record. This was reviewed, discussed, and validated with the Clinical Services Manager.

Observed in Record Review. In 3 of 8 active patient records reviewed with Hospice Aide services, During HV# 1, HV# 3, and RR# 3's patient records review it was noted the organization had not ensured the hospice aide provided care according to the Aide Care Plan. For example: review of HV# 1's Aide Care Plan revealed the tasks of ROM to RUE; ROM to LUE; ROM to RLE; ROM to LLE every week. However, review of the hospice aide visit notes revealed documentation that the tasks had been completed twice a week for five weeks. Review of HV# 3's patient record revealed a frequency of two visits per week. Review of the hospice aide visit notes revealed three missing visits. Further review of HV# 3's patient record revealed one missed visit note dated four days after one of the missed visits with no documentation as to why the visit was missed. Review of HV# 3's updates to the plan of care/IDG documentation during the missed visits time frame revealed no documentation regarding the missed visits. Review of RR# 3's patient record revealed a frequency of four visits per week. Review of the hospice aide visit notes revealed one missed visit. Further review of RR# 3's patient record revealed no documentation regarding the missed visit. Review of RR# 3's updates to the plan of care/IDG documentation during the missed visit time frame revealed no documentation regarding the missed visit. This was reviewed, discussed, and validated with Leadership.

Observed in Record Review. In 1 of 8 active patient records reviewed with Hospice aide, During HV# 1's patient records review it was noted the registered nurse (RN) had not ensured the Aide Care Plan had complete written instructions for the hospice aide. For example: review of the Aide Care Plan revealed the tasks of ROM [range of motion] to RUE [right upper extremities]; ROM to LUE [left upper extremities]; ROM to RLE [right lower extremities]; ROM to LLE [left lower extremities] with no written directions regarding if the ROM was passive or active, which joints, and how many repetitions. This was reviewed, discussed, and validated with the Clinical Services Manager.

Observed in Leadership Session. The governing body/leadership did not ensure that the following Conditions of Participation were met as determined through observations, documentation, and staff interviews:  - §418.100 and §418.104.

Observed in Record Review. In 4 of 8 active patient records reviewed, During HV# 1, RR# 2, RR# 3, and RR# 4's patient records review it was noted the organization had not ensured it maintained complete and accurate patient records. For example: review of HV# 1's patient record revealed documentation that HV# 1 had a coccyx stage 2 pressure ulcer on the registered nurse (RN) recertification comprehensive assessment. However, review of the skilled nurse (SN) visit notes revealed documentation that there were no skin issues identified on nine of the SN visit notes and one SN visit note documented no skin issues identified under Integumentary and in the narrative note documented the Skilled Nursing Facility (SNF) staff were completing daily dressing changes to the sacrum. Review of RR# 2's patient record revealed a RN supervisory visit note dated six days after the start of care with documentation the Home Health Aide was following the care plan and respected the patient rights related to privacy, dignity, confidentiality and personal belongings and property. However, the hospice aide's first visit note is dated one day after the RN supervisory visit note. Review of RR# 3’s patient record revealed an update to the plan of care/IDG dated 23 days prior to the surveyor review of the record with the goal “patient COPD exacerbation will resolve with ABX therapy and steroids [date eight days]. Resolved [date 10 days after the date of the update to the plan of care/IDG]”. Review of RR# 4’s patient record revealed an update to the plan of care/IDG dated 79 days prior to the surveyor review of the record with documentation of the goal “assess for hallucination frequency with visits x 30 days [date 80 days after the update to the plan of care/IDG]. Further review of the update to the plan of care/IDG revealed the goals “skin will remain intact x1 month [date 80 days after the update to the plan of care/IDG] and “Patient will not miss medication doses x2 weeks [date 64 days after the update to the plan of care/IDG]. Further review of RR# 4’s patient record revealed five subsequent updates to the plan of care/IDG with the same goals, time frames, and date. This was reviewed, discussed, and validated by Leadership.

Observed in Patient Home. In 2 of 2 home visits conducted with medication reconciliation, During HV# 2 and HV# 3's patient record review it was noted the organization had not ensured the patient's records contained information that reflected the patient's care, treatment, or services. For example: during HV# 2's home observation the Registered Nurse (RN) was observed completing a medication profile review with the skilled nursing facility (SNF) staff. Review of the HV# 2's medication profile revealed Levothyroxin 125 mcg daily started on admission. However, review of the SNF's medication administration record (MAR) revealed no Levothyroxin. Further review of the SNF record revealed a MAR review by the SNF dated 44 days prior to the home observation with no order for Levothyroxin. During HV# 3's home observation the RN was observed completing a medication review with the assisted living facility (ALF) staff. Review of HV# 3's ALF medication administration record revealed Tramadol 50mg at bedtime dated 34 days prior to the home observation. However review of HV# 3's medication profile revealed no documentation of Tramadol This was reviewed, discussed, and validated with the Clinical Services Manager. Observed in Record Review. In 1 of 8 active patient records reviewed, During RR# 2's patient record review it was noted the organization had not ensured the patient record contained information that reflected the patient's care, treatment, or services. For example: review of RR# 2's patient record revealed a Music Therapy order for an evaluation. Review of RR# 2's patient record revealed no documentation of a Music Therapy evaluation. Further review of the patient record revealed documentation in the update to the plan of care/IDG that the Music Therapist had provided music therapy. However, review of the Music Therapist visit notes revealed the first documented visit was approximately 20 days after the update to the plan of care/IDG. This was reviewed, discussed, and validated with the Clinical Services Manager.