Adoration Home Health

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on Clinical Record Review and staff interview, it was determined the Agency Staff failed to ensure all patients (#1-#17) had an individualized plan of care that identified the patient-specific measurable outcomes and goals which were established, periodically reviewed, and signed by the patients physician or practitioner, This had the potential to affect all patients on census in that a clinician should have the ability to measure and document any pain the patient may have had prior to treatment, during the delivery of care and treatment, after treatment or as an unusual symptom. Without the ability to measure and reassess or remeasure the patients pain, there is no way a physician or practitioner can make an informed decision to intervene with changes to Plan of Care. It was determined during review, that all records (#1-#17) lacked pain parameters. Skilled Nurse was asking about pain on each visit & documenting it in the patients EMR (Electronic Medical Record). There was no pain parameter set for any patient, even those with a potential for needing a focused pain assessment and intervention for pain secondary to wounds or treatments. On 10/23/2024 at 12:40 PM, Agency Representatives were asked about the lack of pain parameters and Staff #1 stated,” No, there are no parameters for pain. We need to do some teaching.””

“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 Clinical Record review and staff interview, it was determined the Agency failed to assure Oxygen (O2) was included in a review for all other Patient medications 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: Clinical Record #1 revealed: A) Document titled “Home Health Certification And Plan of Care” with dates of 08/09/24-10/07/24 listed a diagnosis of “Dependence on supplemental Oxygen.” B) A report titled “Client Medication Report” listed Oxygen, 2lnc (2 liters by nasal cannula), when viewed on the agency EMR (electronic medical record), the O2 is highlighted in the color blue. At the bottom of the computer screen, it states “Meds (medications) displayed with a blue background will not be tested for drug interactions.” Clinical Record #7 revealed: A) Document titled “Home Health Certification And Plan of Care” with dates of 08/26/24-10/24/24 listed a diagnosis of “Dependence on supplemental Oxygen.” B) A report titled “Client Medication Report” listed Oxygen 2 liters PRN (as needed) for SOB (shortness of breath). When viewed on the agency EMR (electronic medical record), the O2 is highlighted in the color blue. At the bottom of the computer screen, it states “Meds (medications) displayed with a blue background will not be tested for drug interactions.” Clinical Record #14 revealed: A) Document titled “Home Health Certification And Plan of Care” with dates of 09/14/2024-11/12/2024 listed a diagnosis of “Dependence on supplemental Oxygen.” B) A report titled “Client Medication Report” listed Oxygen 2 liters PRN (as needed) for SOB (shortness of breath). When viewed on the agency EMR (electronic medical record), the O2 is highlighted in the color blue. At the bottom of the computer screen, it states “Meds (medications) displayed with a blue background will not be tested for drug interactions.” On 10/23/2024 1:30 PM, Agency Representatives were asked if there was any documentation the oxygen had been checked against all other drugs. Agency Representative #1, “No.” We haven’t checked another way.”