Avera at Home of Spencer Hospital

“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, agency policy review, home visit observation, and staff interview, the agency failed to complete a drug regimen review with each comprehensive assessment and identify patient specific medication issues for 2 of 7 sampled patients (Patients #1 and #2). Failure to complete a drug regimen review with each comprehensive assessment placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency’s policy titled Medication Profile, dated 11/9/23, all patients will have a current, accurate medication profile in their clinical record. The medication profile will be updated for each patient to reflect current medications, and new or discontinued medications. The drug regimen review (DRR) includes a review of all medications the patient is currently taking. A DRR will be performed at the time of initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication. During an interview on 4/3/24 at 10:55 AM, the Administrator reported DRRs are completed with the comprehensive assessments at start of care, resumption of care, recertification, discharge, and when new medication is added. The nurse facilitating the visit completes the DRR. 1.Patient #1 had a start of care (SOC) date of 1/8/2024 and received services from the agency. Clinical record review and patient interview revealed the following: a. The Plans of Care (POC) dated 1/8/24 to 3/7/24 and 3/8/24 to 5/8/24 included orders for Melatonin 3 milligram (MG) oral tablet to be taken at bedtime as needed for sleep. b. The medication profile report dated 4/1/24 identified Melatonin 3mg oral tablet to be taken as needed for sleep as a active medication for the patient. c. The recertification comprehensive assessment visit note, dated 3/4/24, included documentation a DRR had been completed. During a home visit observation on 4/1/24 at 1:00 PM with Staff C, Registered Nurse (RN), an interview with the patient revealed the patient has not taken the melatonin in months and does not have it at the residence. The DRR failed to include an accurate list of prescribed and over the counter medications for the patient. 2. Patient #2 had a SOC date of 6/7/2022 and received services from the agency. Clinical record review and patient interview revealed the following: a. The Plan of Care (POC) dated 3/28/24 to 5/26/24 included orders for Brimonidine 0.2% solution ophthalmic (eye) drops with instructions to put 1 drop in the right eye three times daily for glaucoma. b. The recertification comprehensive assessment visit note, dated 3/26/24, included documentation a DRR had been completed. During a home visit observation on 4/2/24 at 8:15 AM with Staff C, Registered Nurse (RN), an interview with the patient revealed the patient was also utilizing Dorzolamide 22.3mg-Timolol 6.8mg/millimeters 22.3-6.8% solution with instructions to put 1 drop in both eyes two times a day and Latanoprost .005% solution with instructions to put 1 drop in right eye at bedtime. Patient reported she had been taking these for a long time. The DRR failed to include an accurate list of prescribed and over the counter medications for the patient. The above findings were reviewed with the Administrator and Clinical Manager. The agency did not provide any further information prior to the end of the survey.”

“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 observation, clinical record, agency policy and patient interview, the agency failed to include all Durable Medical Equipment (DME) and treatments in Plans of Care for 4 of 7 sampled patients (Patients #1, #3, #4, and #6). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services according to assessed needs and physician orders. 2. Patient #1 had a start of care date of 1/8/24 and received services from the agency. The POC, dated 3/8/24 to 5/8/24, included the following DME: stool riser, cardiac monitor, cane, CPAP, B/P Cuff, shower chair, scale, nebulizer, med box, lift chair, grabber-reacher and grab bars. During an observation home visit on 4/1/24 at 1:00 PM with Staff C, RN, the surveyor observed an oxygen concentrator and portable oxygen in the patient’s home. During the same home visit, the patient stated he/she started using the oxygen about a month ago and he uses it as needed. The POC failed to include the DME oxygen and supplies. 3. Patient #4 had a start of care date of 3/14/24 and received services from the agency. Review of the clinical record revealed the following: a. The POC, dated 3/14/24 to 5/12/24, included the following DME used by the patient: walker, cane, med planner, oxygen and supplies, grab bars, hand held shower, and incontinent supplies. b. The initial and comprehensive assessment, dated 3/14/24 identified the patient had a wound to the left ankle that required weekly wound care by the nurse. c. The physical therapy note, dated 3/15/24 identified the patient was walking with a walking boot. The POC failed to identify the DME wound supplies and walking boot. 4. Patient #6 had a start of care date of 2/20/21 and received services from the agency. Review of the clinical record revealed the following: The POC, dated 2/10/23 to 4/10/23, included the following DME: hand held shower, grab bars-toilet, grab bars-shower/tub, diabetic supplies, automatic med planner, wheelchair, shower chair, scale, pill cutter, med box, lift chair, and lifeline. The nurse visit note, dated 3/6/23, identified the patient was using an ace wrap to her right knee for support. The POC failed to identify the DME ace wrap. The above information was provided to the Administrator and Clinical Manager. The agency did not provide any additional information prior to the end of the survey. According to the agency policy, titled Home Health Plan of Care, dated 11/10/23, the clinical plan of care incudes: medications, treatments, supplies and equipment required. 1. Patient #3 had a start of care date of 10/14/21 and received services from the agency. The plan of care (POC), dated 2/1/24 to 3/31/24, included the following DME: long handle shoehorn, cane, CPAP, bath bench, B/P cuff, walker, nebulizer, lifeline, incontinent supplies, grab bars-shower/tub, glucose monitor and supplies, diabetic supplies. During an observation home visit on 4/2/24 at 1:00 PM with Staff D, Registered Nurse (RN) the surveyor observed the patient utilized a cushion in his/her recliner and a reacher. During the same home visit the patient stated he/she used the equipment for 10 to 13 years. The POC failed to include the DME chair cushion and reacher utilized by the patient.”