D W Mcmillan 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), observations, agency policy and procedures and staff interviews, it was determined the agency failed to keep the medication profile (MP) current. This did affect two of four home visits (HV) including HV # 1, HV # 3, and two of three active MR reviews including MR # 2 and MR # 4, 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 patient’s 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 medication list... to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, cream and topical ointments... 3.MR # 4 was admitted on 9/30/24 with diagnoses including Lobar Pneumonia, Unspecified Organism, and Unspecified Atrial Fibrillation. Review of the SN Visit Report documentation dated 9/30/24 shows patient was on oxygen via nasal cannula intermittent. The CMR dated 9/30/24 revealed no documentation of oxygen on the MP. An interview was conducted on 6/26/25 at 12:58 PM with EI # 1 who confirmed the agency failed to ensure medications were reconciled and all current medications were listed on the MP. 4.HV # 3 was admitted on 5/27/25 with diagnoses including Encounter for Surgical Aftercare following Surgery on the Circulatory System, and Atherosclerosis of Aorta. Review of the HHC and POC certification period 5/27/25 to 7/25/25 revealed orders for the SN to visit two times for one week, then once a week for eight weeks, Physical Therapy (PT) to visit once a week for one week then, three times a week for one week, two times a week for three weeks, then once a week for three weeks, and Occupational Therapy to visit once a week for four weeks. A HV was conducted on 6/24/25 at 1:44 PM with EI # 3, Physical Therapy Assistant, (PTA). A comparison was made between medications observed in the home and the MP dated 6/24/25 provided by the agency prior to HV. The following medications were on the MP, but “she no longer takes those and hasn’t for several months” per the caregiver. a. Clearlax 17 Gram/Dose Oral Powder, take only as needed. b. Clopidogrel 75 mg (milligram) tablet, daily. c. Estradiol 2 mg tablet, daily. d. Ondansetron 4 mg disintegrating tablet, take only as needed, every 6 hours. An interview was conducted on 6/24/25 at 2:15 PM with EI # 3 who confirmed staff failed to follow agency policy for medication reconciliation and failed to keep the medication profile current. 1. HV # 1 was admitted to the agency on 3/13/24 with diagnoses including Encounter for Fitting and Adjustment of Urinary Device and Hypertensive Chronic Kidney Disease Review of the Home Health Certification (HHC) and Plan of Care (POC) for certification period 5/7/25 to 7/5/25 revealed orders for the skilled nurse (SN) to visit once for one week effective 5/25/25 and once every four weeks, thereafter. A HV was conducted on 6/24/25 at 1:10 PM to observe care provided by Employee Identifier (EI) # 2, Licensed Practical Nurse (LPN). During the HV, HV # 1’s medicine list was compared to the medications the patient is currently taking. The following medications were noted on the list but not observed in the home: a. Midodrine 10 mg (milligram) tablets by mouth (PO), one daily as needed for blood pressure below 90/60. HV # 1’s caregiver (CG) stated “he/she stopped that over a year ago.” b. Pantoprazole 40 mg tablets, one tablet PO every evening. The CG stated HV # 1 “stopped taking that pill seven to eight months ago.” c. Sodium Bicarbonate 650 mg tablet, take one tablet three x (times) daily. The CG stated he/she also stopped taking this medication “seven to eight months ago.” An interview was conducted on 6/26/25 at 12:43 PM with EI # 1, Patient Care Manager (PCM), who confirmed staff failed to keep the medication profile current per agency policy. 2. MR # 2 was admitted to the agency on 10/6/24 with diagnoses including Encounter for Fitting and Adjustment of Urinary Device, Unspecified Atrial Fibrillation, and Encounter for Attention to Gastrostomy. Review of the MR Client Medication Report (CMR) dated 6/3/25 revealed no documentation of a nutritional/dietary supplement to administer thru the gastrostomy tube (g-tube). An interview was conducted on 6/26/25 at 1:08 PM with EI # 1, who confirmed MR # 2 did receive a nutritional/dietary supplement thru his/her g-tube, there was no documentation of the nutritional/dietary supplement on the CMR and confirmed staff failed to keep the medication profile current per agency policy.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the agency failed to ensure staff developed an individualized Plan of Care (POC) to care for a patient’s gastrostomy tube (g-tube). This deficient practice did affect one of one active MR’s reviewed of a patient with a g-tube including MR # 2, and had the potential to negatively affect all patients with g-tubes served by the agency. Findings include: Agency Policy: Plan of Care Policy Number: 2.1.007 Revised Date: 9/1/24 Purpose: To assure an appropriate POC is developed and revised in a timely manner for each patient. Policy: Each patient has an individualized 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: 1. A POC is developed for all patients... 2. The POC includes: ...e. nutritional requirements... i. patient specific interventions... 1. MR # 2 was admitted to the agency on 10/6/24 with diagnoses of Encounter for Fitting and Adjustment of Urinary Device, Unspecified Atrial Fibrillation, and Encounter for Attention to Gastrostomy. Review of the MR Home Health Certification (HHC) and Plan of Care (POC) dated 6/3/25 revealed Skilled Nurse (SN) visits, effective 6/15/25, once a week for one week then one visit every four weeks. Further review of the HHC and POC revealed documentation of DME (Durable Medical Equipment) and Supplies... Feeding Tube Supplies... Review of the SN visit note dated 6/16/25 revealed in a narrative,... feeding tube intact and patent... Review of the medications listed in the Client Medication Report (CMR) revealed no documentation of a nutritional supplement to be administered thru the g-tube. There was no documentation in the POC for care of the patients g-tube or the nutritional supplement to be administered. An interview was conducted on 6/26/25 at 1:08 PM with Employee Identifier (EI) # 1, Patient Care Manager (PCM), who confirmed there was no documentation in the POC for care of the patient’s g-tube or nutritional supplement to be administered.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on medical record (MR) review, agency policy and procedure, and interview with staff, it was determined the agency failed to ensure wounds were assessed and measured per agency policy. This deficient practice affected one of six patients reviewed with wounds including Home Visit (HV) # 3 and had the potential to negatively affect all patients with wounds. Findings include: Agency Policy: Wound Assessment, Documentation, and Photography Policy Number: 2.2.001 Revised: 9/1/24 Purpose: To ensure the accurate and consistent assessment and documentation of wounds. Policy: Upon initial and subsequently as indicated below, all wounds will be assessed with appropriate documentation in the medical record... Unless otherwise ordered by the physician, the qualified clinician...will assess wounds at least: Weekly for patients...receiving daily wound care performed by the agency, have an infected wound... Every other week for patients receiving wound care by the agency at least at a frequency less than daily... The assessment includes measurement of the length, width, and depth... 1.HV # 3 was admitted on 5/27/25 with diagnoses including Encounter for Surgical Aftercare following Surgery on the Circulatory System, and Atherosclerosis of Aorta. Review of the Home Health Certification and Plan of Care dated 5/27/25 revealed physician’s orders for Skilled Nurse (SN) two times a week for one week, then one time a week for eight weeks to perform procedure of care to wound # 1, closed incision/suture line to left lower quadrant of abdomen, wound # 2, left inferior thoracic open surgical incision, and wound # 3, right buttock Stage I pressure ulcer. Review of SN Visit Note Reports dated 5/27/25 to 6/18/25 revealed no documentation of each of the wound measurements. An interview was conducted on 6/26/25 at 12:50 PM with Employee Identifier # 1, Patient Care Manager, who confirmed the staff failed to measure wounds per agency policy.”