Dch Home Health Care Agency

“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 review of medical records (MR), observations, agency policy and procedure, and interviews, it was determined the agency failed to keep the medication profile current. This policy did affect six out of seven home visits (HV) including HV # 1, HV # 7, HV # 4, HV # 5, HV # 2, and HV # 6, and had the potential to affect all persons served by the agency. Findings include: Agency Policy: Medication Assessment and Reconciliation Policy Number: None Reviewed Date: September 2022 Policy: Assessment of the patient’s medications and reconciliation of physician’s orders with medications available in the home will be done on every nurse visit to the home by the Registered Nurse (RN) or Licensed Practical Nurse (LPN). Other disciplines visiting the patient such as the Physical Therapist (PT), Licensed Physical Therapy Assistant) (LPTA), Occupational Therapist (OT), Certified Occupational Therapy Assistant (COTA), Speech Therapist (ST), Medical Social Worker (MSW), Home Health Aide (HHA) will ask the patient if there has been a change in their medications and if the response is yes, the primary care manager (PCM) will be notified. In the event of a therapy only case, the therapy manager will assume responsibility for medication assessment and reconciliation in collaboration with the clinical manager. Purpose: To ensure the medication list maintained within the patient’s medical record is up to date and current with medications in the home. To ensure the patient is taking the correct medications at the correct times as ordered by the physician. Procedure: The Skilled Nurse (SN)/ care manager (CM) will take actions to assure accurate reconciliation of patient medications by following these steps: A. The SN/CM is to review all medications in the home on every visit to ensure patients are taking medication as prescribed and the patient’s medication profile is always accurate and up to date... 5. HV # 2 was admitted to the agency on 7/3/25 with diagnoses including Acute Kidney Failure, Unspecified and Low Back Pain, Unspecified. Review of the HHCPOC for the certification period 7/3/25 to 8/31/25 revealed orders for the SN to visit once a week for one week, two times a week for one week and once a week for three weeks. Further review of HV # 2’s MR revealed orders for PT evaluation once a week for one week effective 7/13/25. A HV was conducted on 7/15/25 at 1:40 PM to observe care provided by EI # 9, PT. EI # 10, Patient Care PCM, was also present on the visit. During the HV, HV # 2’s CMR was compared to the medications the patient is currently taking. The following medication was observed in the home but not on the medication profile: a. Humalog Kwikpen 100 U (units) with a fill date of 2/6/24. HV # 2 stated he/she still takes the medication. An interview was conducted on 7/17/25 at 11:25 AM with EI # 2, who confirmed staff failed to keep the medication profile current. 6. HV # 6 was admitted to the agency on 4/26/25 with diagnoses including Non-Pressure Chronic Ulcer of Other Part of Right Lower Leg with Fat Layer Exposed and Encounter for Change and Removal of Non-Surgical Wound Dressing. A review of the HHCPOC for the certification period 6/25/25 to 8/23/25 revealed orders for the SN to visit two times a week for two weeks then once a week for seven weeks. A HV was conducted on 7/16/25 at 8:36 AM to observe care provided by EI # 5, RN. EI # 6, RN, Intake Coordinator was also present on the visit. During the HV, HV # 6’s CMR was compared to the medications the patient was currently taking. The following medication was observed in the home but not on the medication profile: a. Ropinirole HCL (Hydrochloride) 0.5 mg tablets, take two tablets at 5:00 PM, and one tablet at HS (bedtime), with a fill date of 5/8/25. HV # 6 stated he/she has taken the medication for restless legs for years. An interview was conducted on 7/17/25 at 11:33 AM with EI # 2, who confirmed staff failed to keep the medication profile current. 3. HV # 4 was admitted to the agency on 6/8/25 with a diagnosis of Wedge Compression Fracture of T11-T12 Vertebra, Subsequent Encounter for Fracture with Routine Healing, and certified for care 6/8/25 to 8/6/25. Review of the HHCPOC for the certification period 6/8/25 to 8/6/25 revealed orders for the SN to visit three times a week for one week, two times a week for one week and once a week for seven weeks. The PT was ordered to visit two times a week for three weeks and once a week for two weeks. The OT was ordered to visit once a week for four weeks. A HV was conducted on 7/15/25 at 3:17 PM to observe care provided by EI # 4, ST. EI # 6, RN was also present during the visit. During the visit, the CMR dated 7/15/25 was compared to the medications found in the home. The following discrepancy was observed: a. Over the Counter Vita Fusion Power C, take three gummies daily was in the home and not on the medicine list. HV # 4, stated, “I have been taking one gummy daily for about three months.” An interview was conducted on 7/17/25 at 11:31 AM with EI # 8, Home Health Assistant Director, who confirmed the staff failed to keep the medication profile current. 4. HV # 5 was admitted to the agency on 7/12/25 with a diagnosis of Cerebral Infarction Unspecified and certified for care 7/12/25 to 9/9/25. Review of the HHCPOC for the certification period 7/12/25 to 9/9/25 revealed orders for the SN to visit one time a week for one week, two times a week for two weeks and two times every three weeks for three weeks. A HV was conducted on 7/15/25 at 12:29 PM to observe care provided by EI # 3, OT. EI # 6, RN was also present during the visit. During the visit, the CMR dated 7/15/25 was compared to the medications observed in the home. The following discrepancy was observed: a. Megestrol 40 milligram tablet, take one tab twice daily for appetite with fill date 7/5/25 was in the home and not on the medicine list. HV # 5’s caregiver, reported the patient had been taking the medication since the fill date. An interview was conducted on 7/17/25 at 11:37 AM with EI # 8, Home Health Assistant Director, who confirmed the staff failed to keep the medication profile current. 1. HV # 1 was admitted to the agency on 6/25/25 with a diagnosis of Type 2 Diabetes Mellitus with Hypoglycemia, Without Coma. Review of the Home Health Certification and Plan of Care (HHCPOC) for the Certification Period 6/25/25 to 8/23/25 revealed an order for SN Visits once weekly for six weeks. A HV was conducted on 7/15/25 at 11:25 AM to observe care provided by EI # 8, Home Health Aide (HHA). EI # 1, Home Health Director, was present for the HV. During the visit, the Client Medication Report (CMR) dated 7/15/25 was compared to the medications observed in the home. The following discrepancies were observed: a. Januvia 50 milligram (mg) tablet, one tablet two times daily with a start date of 7/2/25, was listed on the CMR. The patient’s spouse stated HV # 1 had not taken the medication since released from the hospital on 6/23/25. b. Metformin 500 mg tablet, one tablet two times daily with a start date of 7/2/25, was listed on the CMR. The patient’s spouse stated HV # 1 had not taken the medication since released from the hospital on 6/23/25. An interview was conducted on 7/17/25 at 11:25 AM with EI # 2, Assistant Home Health Director, who confirmed staff failed to keep the medication profile current. 2. HV # 7 was admitted to the agency on 10/31/24 with a diagnosis of Other Forms of Systemic Lupus Erythematosus. Review of the HHCPOC dated 6/28/25 to 8/26/25 revealed SN visits were ordered once weekly for eight weeks. A HV was conducted on 7/16/25 at 10: 05 AM to observe care provided by EI # 7, RN. EI # 1 was present on the HV. During the visit, the CMR dated 7/15/25 was compared to the medications observed in the home. a. Meloxicam 15 mg, one tablet daily, with a fill date of 3/27/25, was observed in the home and was not listed on the CMR. HV # 7 stated they take the medication daily. b. Lasix 20 mg, one tablet daily, with a fill date of 5/13/25, was observed in the home and was not listed on the CMR. The patient stated they last took the medication on Sunday 7/13/25. c. Prednisone 5 mg, three tablets daily, with a fill date of 5/13/25, was observed in the home and was not listed on the CMR. The patient stated they take the medication daily. d. Methenamine One Gram tablet, one tablet two times daily, with a fill date of 6/15/25, was observed in the home and was not listed on the CMR. The patient stated they take the medication every day to prevent recurrent Urinary Tract Infections.. e. Duloxetine 30 mg, one tablet daily, with a fill date of 6/19/25, was observed in the home and was not listed on the CMR. HV # 7 stated they last took the medication on 7/15/25. f. Tizanidine 4 mg, one tablet daily as needed for muscle spasms, was observed in the home and was not listed on the CMR. g. Clindamycin 300 mg, one tablet twice daily for 14 days, with a fill date of 7/4/25, was observed in the home and was not listed on the CMR. The patient stated they had been taking the medication since 7/7/25. h. Hydroxychloroquine 200 mg, two tablets twice daily, with a fill date of 5/17/25 was observed in the home. The medication was listed on the CMR with instructions to take two tablets at bedtime. i. Pregabalin 200 mg, one capsule three times daily, with a fill date of 6/22/25 was observed in the home. The medication was listed on the CMR with instructions to take one capsule twice daily. j. Pregabalin 150 mg, one capsule by mouth before lunch, was listed on the CMR. The patient stated the medication was discontinued on 6/22/25. An interview was conducted on 7/17/25 at 11:20 AM with EI # 2, who confirmed staff failed to keep the medication profile current.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observations, review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the facility failed to ensure: 1. Staff obtained and adhered to physician’s orders for wound care. 2. Staff followed the physician’s order for gastrostomy tube care. This affected Home Visit (HV) # 7, in one of seven MRs reviewed with wound care orders and MR # 3 in one of one MRs reviewed with a gastrostomy tube and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Physician/Non-Physician Provider Order/Progress and Goal Update Revised Date: 12/21 Policy: Orders received from the physician or non-physician provider are entered into the patient’s Electronic Medical Record (EMR). All orders are reviewed prior to care to insure that care is being provided according to the most recent order. The physician or non-physician provider will serve as the ongoing revision of the patient’s plan of care (POC). No care will be provided without a physician’s or non-physician provider order. Purpose: To update the POC with all orders received from the physician or non-physician provider. To provide the physician and all members of the patient care team with documentation of new or changed problems, new or changed orders, and the expected outcome. Procedure: .a. ...All orders are reviewed for accuracy prior to administering medications, treatments, or delivering care. Special Points: a. Patients are evaluated and reassessed based on the care plan and established goals. Staff assesses patient for progress toward goals and contacts physician or non-physician provider to revise plans and goals for the patient as appropriate. Agency Policy: Enteral Tube Feeding, Intermittent, Gastrostomy, and Jejunostomy Revision Date: 11/18/24 ...Implementation: ...Verify enteral tube placement using at least two of the following methods: Observe for a change in the external length or the incremental marking on the tube at the exit site to determine whether the tube has migrated. Observe for a change in the volume of aspirate from the external tube... Review routine chest and abdominal x-ray reports. Aspirate the enteral tube contents and inspect the visual characteristics of the tube aspirate... 1. HV # 7 was admitted to the agency on 10/31/24 with a primary diagnosis of Other Forms of Systemic Lupus Erythematosus. A HV was conducted on 7/16/25 at 10:05 AM with EI # 7, Registered Nurse, who provided wound care for HV # 7. EI # 1, Home Health Director, was present on the visit. A review of the Home Health Certification and Plan of Care (HHCPOC) for the Certification Period dated 6/28/25 to 8/26/25 revealed orders for the Skilled Nurse (SN) to provide wound care to wound # 2, right fourth finger, SLE Vasculitis Ulcer, and wound # 8, right distal forearm burn. EI # 7 performed wound care to wound # 2, right fourth finger, and an unidentified wound on the left great toe. There was no wound care orders for the wound care on the left great toe. An interview was conducted on 7/17/25 at 11:20 AM with EI # 2, Assistant Home Health Director, who confirmed staff failed to obtain and adhere to wound care orders. 2. MR # 3 was admitted to the agency on 6/14/25 with diagnoses that included fracture of orbital floor, right side and Maxillary Fracture, right side, following a gun shot wound. Review of the HHCPOC revealed orders for the SN to visit once weekly for two weeks, then twice weekly for one week, then once weekly for three weeks. Further review of the HHCPOC revealed orders for the SN for preparation, administration, and instruction of gastrostomy feeding... Check tube placement and residual prior to administering feedings... Caregiver to perform care when SN is not scheduled to visit. Review of seven of seven SN Visit Reports dated 6/14/25, 6/20/25, 6/24/25, 6/27/25, 7/1/25, 7/8/25, and 7/16/25 revealed no documentation the SN checked the gastrostomy tube placement or the residual. An interview was conducted on 7/17/25 at 11:15 AM with EI # 2, who confirmed staff failed to follow the physician’s order for gastrostomy tube care.”