Every finding on record at Arc Therapy Services LLC

Observed in Record Review. In 1 of 6 active patient records reviewed, During HV# 1's record review it was noted the organization had not ensured it maintained an accurate patient record. For example: review of the start of care RN comprehensive assessment revealed documentation HV# 1 had two falls in the month previous to the start of care. Further review of HV# 1's patient record revealed five updates to the plan of care/interdisciplinary group (IDG) with RN documentation updates that included the HV# 1 had two falls in the last month. Review of the patient record revealed no documentation HV# 1 had fallen since the start of care. This was reviewed, discussed, and validated by the Regional Director of Survey Readiness.

Observed in Record Review. In 6 of 6 active patient records reviewed, During HV# 1, HV# 2, HV# 3, RR# 6, RR# 7, and RR# 8's patient records reviewed it was noted the organization had not ensured the patient plans of care were based on the patient's goals. For example: review of HV# 1's patient record revealed documentation the patient's acceptable pain level was a 2/10. However, review of the plan of care revealed a pain goal of 4/10. Review of HV# 2's patient record revealed a patient pain goal of 0/10 and a documented patient acceptable pain goal of 3/10. However, review of the plan of care revealed Patient will maintain effective pain control through out end of life with no individual measureable goal. Review of HV# 3's patient record revealed a patient pain goal of 0/10. However, review of the plan of care revealed a pain goal of 4/10. Review of RR# 6's patient record revealed a patient pain goal of 0/10. However, review of the plan of care revealed a pain goal of 4/10. Review of RR# 7's patient record revealed a patient pain goal of 2/10. However, review of the plan of care revealed a pain goal of 4/10. Review of RR# 8's patient record revealed a patient pain goal of 0. However, review of the plan of care revealed a pain goal of 4/10. This was reviewed, discussed, and validated by the Regional Director of Survey Readiness.

Observed in Record Review. In 3 of 6 active patient records reviewed, During HV# 1's patient record review it was noted the organization had not ensured the patient plans of care included all services needed for the palliation and management of terminal illness related to conditions, including interventions to manage symptoms. For example: review of HV# 1's patient record revealed a co-morbidity diagnosis of diabetes mellitus. Review of the plan of care revealed HV# 1 was receiving insulin daily; but the plan of care did not address diabetic management. This was reviewed, discussed, and validated by the Regional Director of Survey Readiness.

Observed in Record Review. During HV# 2, and HV# 3's patient records review it was noted the organization had not ensured the patient plans of care included all services needed for the palliation and management of terminal illness related to conditions, including medical supplies and appliances necessary to meet the patient's needs. For example: during HV# 2's home observation it was noted HV# 2 had a Bipap machine present in the home and HV# 2 shared the Bipap machine was used at night. However, the Bipap machine was not found on the current plan of care. During HV# 3's home observation it was noted HV# 3 had a power operated vehicle (POV)/scooter. However, the POV/scooter was not found on the current plan of care. This was reviewed, discussed, and validated by the Regional Director of Survey Readiness.

Observed in Patient Home. In 1 of 1 home visits conducted with vital sign equipment, During HV# 2's home observation it was noted the organization had not implemented their infection prevention and control activities when doing the following: Cleaning and performing disinfection of medical supplies and devices. For example: during HV# 2's home observation the registered nurse (RN) cleaned the stethoscope and B/P cuff with Sani wipes and had not allowed to dry for 2 minutes prior to replacing the equipment into the clinical bag. This was discussed and validated by the Director of Clinical Services. Observed in Patient Home. In 1 of 3 home visits conducted, During HV# 2's home observation it was noted the registered nurse (RN) did not follow the organization's Bag Technique policy.  For example: the RN was observed entering the nurse bag on multiple occasions without performing hand hygiene prior to entering the nurse bag per organization's policy. This was discussed and validated with the Director of Clinical Services.

Observed in HR File Review. In 2 of 11 HR files reviewed, During review of the Medical Director and alternate Medical Director's HR files revealed the organization had not ensured competencies were defined for the Medical Director. This was reviewed, discussed, and validated by the Director of Business Operations. Observed in HR File Review. In 2 of 11 HR files reviewed, During the Medical Director and alternate Medical Director's HR files review it was noted the organization had not ensured staff competence was initially assessed and documented as part of orientation. For example: review of the HR files revealed no documentation of initial competencies. This was reviewed, discussed, and validated by the Director of Business Operations.