Worth County Phns

“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 interviews, clinical record reviews, and policy review, the agency failed to complete a Drug Regimen Review (DRR) with all required components for 6 of 6 sampled patients requiring DRRs (Patients #1, #2, #3, #4, #6 and #7). Failure to perform a complete DRR, increased the risk for patients to experience potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Findings include: 5. Patient #3 had an admission date of 11/7/19. Review of the clinical record revealed the following: a. The POC, dated 6/12/24 to 8/10/24, included orders for skilled nursing services and orders for medications. b. The comprehensive assessment, dated 6/21/24, identified the potential drug interactions and the duplicate therapies. The comprehensive assessment failed to identify if the medication regimen was effective for the patient, if patient was compliant with all medications, and if there were any medications requiring laboratory monitoring. The agency failed to address all 5 components of the DRR. 6. Patient #7 had a start of care date of 5/2/24. a. The Plan of Care (POC), dated 5/2/2024 to 6/30/2024, included orders for skilled nursing services and orders for medications. b. The comprehensive assessment, dated 5/2/24, identified the potential drug interactions and duplicate therapies. The comprehensive assessment failed to identify if the medication regimen was effective for the patient, if patient was compliant with all medications, and if there were any medications requiring laboratory monitoring. The agency failed to address all 5 components of the DRR. The above findings were reviewed with the agency Administrator and Clinical Manager. According to the agency policy titled Medication Profile, dated 12/2022, the Registered Nurse will complete a Drug Regiment Review (DRR) for each client at the time of admission and when a comprehensive assessment is due. The DRR is to identify possible ineffective drug therapy, adverse reactions, significant side effects, drug allergies, and contraindicated medications. During an interview on 7/29/24 at 3:02 PM with Staff B, Clinical Manager, a complete DRR is done on admission, when a medication change occurs, at every recertification, resumption of care, transfer and discharge. The completed DRR is sent to the provider within 24 for hours to review. 1.Patient #1 had an admission date of 1/25/23. Review of the clinical record revealed the following: a. The Plan of Care (POC), dated 7/18/24 to 9/15/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 7/15/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR. 2.Patient #2 had an admission date of 4/16/24. Review of the clinical record revealed the following: a. The POC, dated 6/15/24 to 8/13/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 6/10/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR. 3.Patient #4 had an admission date of 11/23/22. Review of the clinical record revealed the following: a. The POC, dated 7/15/24 to 9/13/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 7/12/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR. 4. Patient #6 had an admission date of 5/16/24. Review of the clinical record revealed the following: a. The POC, dated 5/16/24 to 7/14/24, included orders for skilled nursing services and orders for medications. b. The DRR completed on 5/16/24 identified significant drug interactions and duplicate drug therapy but failed to identify ineffective drug therapy, significant side effects, and noncompliance with drug therapy. The agency failed to address all 5 components of the DRR.”

“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 observations, interviews, record review, and policy review, the agency failed to ensure accurate completion of all components comprising the Plan of Care, including all supplies and equipment used by the patient for 2 of 3 home visit observations (Patients #2 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medication and /or treatments according to the assessed needs and physician orders. Findings include: 2.Patient #2 had a start of care date of 4/16/24. Clinical record review, home visit observation, and accompanying interviews revealed the following: a. The POCs, dated 4/16/24 to 6/14/24 and 6/15/24 to 8/13/24, included the following durable medical equipment (DME) used by the patient: compression stockings, grab bars/safety rails, long handled sponge, hand-held shower, oral medication tray, shower chair, cane, incentive spirometer, chair pedal exerciser, and 4 wheeled walker with seat. b. During a home visit observation on 7/30/24 with Staff C, RN, the surveyor observed a life alert button sitting on the table. An interview with Patient #2 during this same visit revealed the patient has had the life alert button for approximately one year and wears it daily. The POC failed to identify the DME life alert button. The above findings were reviewed with the Administrator and Clinical Manager. Findings include: According to agency policy, Plan of Care, dated October 2023, the Plan of Care shall be completed in full to include all pertinent diagnoses, medication and treatments, and supplies and equipment required. 1. Patient #3 had a start of care date of 11/7/2019. Clinical record review, home visit observation, and accompanying interviews revealed the following: a. The Plan of Care (POC) dated, 6/12/2024 to 8/10/2024, identified the patient used the following equipment: Adult Diapers; Oral medication tray; Hand-held shower; Grab bars/safety rails; Glasses, electric razor, and upper dentures. b. During a home observation visit on 7/30/24 at 11:30 AM, Staff B, Registered Nurse (RN), educated the patient on the importance of using the patient’s walker when moving about through the house. Staff B noted to surveyor the walker was usually by his recliner chair within reach, but was not there during the home observation visit. c. Patient had been hospitalized from 6/19/24 through 6/21/24, related to symptoms of a cardiovascular accident, (stroke). Discharge instructions dated 6/21/24, included instructions to use a walker upon return to the home. d. The POC was not updated to include a walker as part of the medical supplies utilized by the patient. The POC failed to include all of the medical equipment utilized by the patient.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observations, interviews, record review and policy review, the agency failed to maintain the Plan of Care for patients and to update the Plan of Care with any new verbal/interim physician orders for 1 of 2 sampled patients with new orders following a resumption of care (Patient #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to the assessed needs and physician orders. Findings Include: According to the agency policy titled Plan of Care, dated October 2023, the Plan of Care shall be completed in full to include all pertinent diagnoses, medications and treatments, and all verbal orders obtained from the clients physician for changes in the Plan of Care. 1. Patient #3 had a start of care date of 11/7/2019. Clinical record review revealed the following: a. The Plan of Care (POC), dated 6/12/24 to 8/10/24, included orders for regular diet. b. Patient was hospitalized from 6/19/24 to 6/21/24 for symptoms of cerebrovascular accident (stroke). c. Patient had a resumption of care completed on 6/21/24 with hospital discharge instructions to change from a regular diet to a mechanical soft diet with the addition of Ensure (nutritional supplement) three times per day. The agency failed to record all orders in the plan of care. The above findings were reviewed with the agency Administrator and the Clinical Manager.”