Eamc - Lanier Home Health

“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), agency policy and procedures, observations and staff interviews, it was determined the agency failed to keep the medication profile current. This did affect two of five home visits (HV) including HV # 1, and HV # 5 and had the potential to negatively affect all persons served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Revised Date: 7/1/24 Purpose: To provide a process to ensure continuous monitoring of medications in the patient’s home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode... Procedure: 1. The discipline responsible for the drug regimen review will: a. Compare the medication list... to actual medications the patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, cream and topical ointments. 2. HV # 5 was admitted to the agency on 7/15/25 with diagnoses including Venous Insufficiency (chronic) (peripheral), and Non-Pressure Chronic Ulcer of Left Calf with Other Severity. A review of the POC dated 7/15/25 revealed an order for SN (skilled nurse) visits two times a week for nine weeks. A HV was conducted on 8/6/25 at 9:00 AM to observe care provided by EI # 6, Licensed Practical Nurse. During the HV, the ML printed on 8/6/25 and provided to the surveyor was compared to the medications observed in the home. The following discrepancy was observed: Amoxicillin 875 mg-Potassium Clavulanate 125 mg tablet, take one tablet by mouth twice daily for ten days for wound infection was found in the home but not on the ML. A physician’s order dated 7/29/25 confirmed the above medication. An interview was conducted on 8/6/25 at 1:49 PM with EI # 1, who confirmed staff failed to keep the medication profile current. 1. HV # 1 was admitted to the agency on 7/29/25 with a primary Diagnosis of Hemiplegia Following Cerebral Infarction Affecting Left Nondominant Side. A review of the Home Health Certification Plan of Care (POC) dated 7/29/25 revealed an order for Physical Therapy two times a week for two weeks and one time a week for one week. Occupational Therapy one time a week for one week effective week of 8/3/25, and Speech Therapy one time a week for three weeks. A HV was conducted on 8/5/25 at 10:27 AM to observe care provided by Employee Identifier (EI) # 4, Physical Therapy Assistant. During the HV, the Medication List (ML) printed on 8/5/25 and provided to the surveyor was compared to the medications observed in the home. The following discrepancies were observed: Biaxin 500 milligram (mg) take one tablet by mouth twice a day for seven days, with a fill date of 7/28/25, was not listed on the ML. Metronidazole 500 mg take one tablet by mouth twice a day for seven days, with a fill date of 7/29/25, was not listed on the ML. Hydrocodone 7.5/325 mg take one tablet by mouth every four hours as needed for pain, with a fill date of 7/18/25, was not listed on the ML. The following medications were listed on the ML and confirmed by the patient not to be accurate: Nicotine 4 mg Buccal Lozenge 1 lozenge every four to eight hours discontinued 7/28/25. Pataday Once Daily Relief 0.7 % Eye Drops. One drop daily discontinued 7/28/25. Systane Nighttime 94 % - 3 % Eye Ointment one application in left eye at night discontinued 7/28/25. Claritin 10 mg one tablet daily discontinued 7/22/25. An interview was conducted on 8/6/25 at 1:59 PM with EI # 1, Area Administrator, 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 medical record (MR) review, agency policies and procedures, and staff interview, it was determined the agency failed to ensure staff followed the physician’s order for wound care. This affected MR # 8 in one of six MRs reviewed with wound care ordered and had the potential to negatively affect all patients with wounds serviced by the agency. Findings include: Agency Policy: Plan of Care Policy Number: 2.1.007 Revision Date: 4/1/25 Policy: Every patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals, as well as to address specific services being provided. Procedure: ...2. The POC includes: ...b. Types, frequency, and duration of services required... f. Medications and treatments... i. Patient specific interventions... n. All patient care orders... 6. Physician/authorized practitioner’s orders are obtained to update the POC. 7. Medications, treatments, and interventions are provided by authorized agency staff as ordered by the physician or authorized prescriber. Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revision Date: 9/1/24 Procedure: ...2. Perform wound care according to LHC adopted clinical skills guidelines and physician orders. MR # 8 was admitted to the agency on 5/29/25 with diagnoses that included Erythema Intertrigo and Pressure Ulcer of unspecified part of the back. Review of the Home Health Certification and Plan of Care (HHCPOC) from 5/29/25 to 7/27/25 revealed physician orders for Skilled Nurse (SN) to perform/instruct patient/caregiver procedure of wound care to wound # 1 midline vertebrae stage III pressure ulcer every three days and as needed (prn) for soilage or dislodgement. Cleanse with soap and water and wash cloth and pat dry. Cover with RTD (brand) dressing and border gauze dressing. Wound # 2 right upper quadrant intertrigo cleanse with soap and water and wash cloth daily and pat dry. Apply silvadene cream two times daily and prn using clean technique. Instruct patient/caregiver signs/symptoms of wound infection and proper disposal of dressings. Further review of the MR revealed a physician order on 6/5/25 for SN to perform/instruct patient/caregiver procedure of wound care to wound # 1 midline vertebrae stage III pressure ulcer-cleanse with wound cleanser, cover with RTD dressing and border gauze dressing every three days and prn for soiled or dislodged dressing. SN to perform on visit days, caregiver to perform all other days after a successful return demonstration. Wound # 2 right upper quadrant intertrigo-cleanse with soap and water and wash cloth daily and pat dry. Apply silvadene cream two times daily and prn. SN to perform on visit days, caregiver to perform all other days after successful return demonstration. Review of the SN Visit Note Reports (VNR) dated 6/11/25 and 6/25/25,revealed the SN failed to clean the wound with wound cleanser, per the physician’s order. Review of the SN VNR dated 7/2/25, revealed the SN failed to perform the wound care during his/her visit, per the physician’s order. An interview was conducted on 8/6/25 at 1:36 PM with Employee Identifier # 1, Area Administrator, who confirmed staff failed to perform wound care per the physician’s order.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and staff interview, it was determined the agency failed to notify the physician of changes in the patient condition. This affected MR # 1, MR # 8, and MR # 6 in three of thirteen MRs reviewed and had the potential to negatively affect all patients serviced by the agency. Findings include: Agency Policy: Coordination of Care, From Admit Through Discharge Policy Number: 2.1.017 Revision Date: 9/1/24 Policy: The agency provides care and services within an integrated continuum of care system. This is accomplished by: Identifying patient needs through assessment and communication with other health care providers... Coordinating patient care among various disciplines and between in-person and virtual clinicians to ensure that services are continuous and coordinated from admission through discharge. Procedure: ...4. Coordination of care with physician/authorized practitioner: At admission, throughout care, and at discharge, coordination of services is promoted through routine communication with the patient’s physician: a. When changes occur in the patient’s condition or response to treatment. 3. MR # 6 was admitted to the agency on 2/1/25 and resumed for continued care on 2/27/25 with a primary diagnosis of Diabetes Mellitus with Ketoacidosis without coma. A review of the Resumption of Care order dated 2/27/25 revealed an order for the physician to be notified of a glucose level of greater than 250. A review of the SN VNR dated 3/20/25 revealed the patients glucose was reported to the nurse as between 147-325 for the last seven days, no documentation the patient notified the physician or the nurse notified the physician per the order. The nurse documented the patient needed reinforcement for education on new glucose meter due to knowledge deficits. An interview on 8/6/25 at 1:58 PM with EI # 1, confirmed there was no documentation to confirm the physician was notified regarding glucose levels greater than 250 per the physician orders. 1. MR # 1 was admitted to the agency on 5/7/25 with a diagnosis of ST Elevation Myocardial Infarction of Unspecified site. Review of the Home Health Certification and Plan of Care (HHCPOC) dated 7/1/25 to 8/29/25 revealed orders for Skilled Nurse (SN) to instruct patient/caregiver on Myocardial Infarction to include definition, signs/symptoms, signs/symptoms to report, management and causes. Further review of the HHCPOC dated 7/1/25 to 8/29/25 revealed orders for SN to perform up to two as needed visits for cardiac complications such as chest pain, dyspnea, ... increase in weight of five pounds in one week... Review of the SN Visit Report Note (VRN) dated 7/1/25 revealed a documented weight of 245 pounds (lbs) Review of the SN VRN dated 7/7/25 revealed a documented weight of 255 lbs. Further review of the SN VRN dated 7/7/25 revealed the SN documented in his/her assessment the patient had not experienced unwanted weight gain/loss of more than two pounds since the last visit or three pounds in the last week. There was no documentation the SN notified the physician of the ten pound weight gain from 7/1/25 to 7/7/25 per the facility policy. An interview was conducted on 8/6/25 at 2:00 PM with Employee Identifier (EI) # 1, Area Administrator, who confirmed the staff failed to report changes in the patient’s condition to the physician. 2. MR # 8 was admitted to the agency on 5/29/25 with diagnoses that included Erythema Intertrigo and Pressure Ulcer of unspecified part of the back. Review of the HHCPOC dated 5/29/25-7/27/25 revealed orders for SN to instruct patient/caregiver on Peripheral Vascular Disease to include definition, signs and symptoms, signs and symptoms to report... Review of the SN VRN dated 7/2/25 revealed an ankle circumference of 22 centimeters (cm) documented for the left ankle. There was no documentation of the right ankle circumference. Review of the SN VRN dated 7/8/25 revealed an ankle circumference of 32.5 cm documented for the left ankle and 32 cm documented for the right ankle. Further review of the SN VNR dated 7/8/25 revealed the skilled nurse documented in his/her assessment there had not been an increase in ankle circumference of two cm. Review of the SN VNR dated 7/18/25 revealed an ankle circumference of 33.5 cm for the left ankle and 35 cm for the right ankle. Further review of the SN VNR dated 7/18/25 revealed the SN documented in his/her assessment there had not been an increase in ankle circumference of two cm. There was no documentation the SN notified the physician of changes in the patient’s ankle circumference. An interview was conducted on 8/6/25 at 1:36 PM with EI # 1, who confirmed staff failed to report changes in the patient’s condition to the physician.”

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on Medical Record (MR) review, agency policy and procedure, and staff interview, it was determined the agency failed to ensure staff educated the patient and/or caregiver on sliding scale insulin administration. This affected one of four patients reviewed with Diabetes to include MR # 6, and had the potential to affect all patients served by the agency. Findings include: Agency policy: Patient Education Policy Number: 3.001 Revised date: 11/17 Purpose: To describe patient and/or caregiver interactions designed to promote and maximize patient health and safety. Policy: The agency plans, supports and coordinates patient and caregiver education designed to promote optimal patient health and safety. Patients receive oral and/or written information for this purpose on an ongoing basis while being care for by the agency. Procedure: 1. Educational resources are made available through appropriate educational methods to the patient and caregiver based on assess and/or potential learning needs of the patient and caregiver... 6. Per assessed knowledge deficit, patient and caregivers receive oral and/or written information on medication education to include: a. Dosage, route, duration b. Description, purpose, expected actions. c. Potential side affects, contraindications, avoidance of interactions, reactions to report... f. Self-administration and monitoring techniques... k. High alert medications, as appropriate. i. Range order with appropriate dosing interval. 7. Using the progress/visit note, the clinician documents the level of patient/caregiver comprehension, patient/caregiver return demonstration of skill(s) taught, compliance, and any follow up with team members. Concerns are reports to the patient’s physician. 1. MR # 6 was admitted to the agency on 2/1/25 with a primary diagnosis of Diabetes Mellitus with Ketoacidosis without coma. A review of the Home Health Certification and Plan of Care dated 2/1/25 revealed nursing services were ordered to visit one time a week for five weeks, and one time every other week for four weeks, with two as needed visits for signs and symptoms of Hypo/hyperglycemia. Orders included to educate the patient to instruct on prescribed medications to treat diabetes, new or changed medications, high risk medications, and any applicable drug interactions. Orders for Novolog U-100 Insulin Aspart 100 unit/milliliter (mL) solution sliding scale, to be given Subcutaneous with a start date of 1/11/25 without any documentation of the parameters for use. A review of the RN Outcome Assessment Information Set (OASIS) Admission note dated 2/1/25 revealed the patient had no documentation of education on the use of sliding scale insulin and no documentation of the parameters for the sliding scale. A review of the nursing Visit Note Report dated 2/6/25 revealed glucose levels ranging from 109-300 in the last seven days. No documentation of sliding scale use or education documented in the visit note. A review of the nursing Visit Note Report dated 2/10/25 revealed glucose levels documented of 300 or less in the last seven days. No documentation of sliding scale use or education documented in the visit note. A review of the nursing Visit Note Report dated 2/17/25 revealed a glucose level documented of 42 during the visit. The patient was transferred to the hospital and was admitted from 2/17/25 to 2/26/25 related to Hypoglycemia. An interview was conducted on 8/6/25 at 1:58 PM with Employee Identifier # 1, Area Administrator who confirmed there was no documentation of patient education regarding sliding scale use or sliding scale parameters in the medical record prior to the 2/17/25 transfer to the hospital for hypoglycemia.”