Virginia Gay Hospital Home Health Agency

“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 agency staff interviews, clinical record reviews, and policy review, the home health agency failed to ensure the drug regimen review identified at a minimum the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, and/or patient compliance with medications for 3 of 7 sampled patients (Patients #1, #2 and #4). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate and failure to identify actual/ potential concerns increased the potential for unidentified medication interactions and side effect risks to the patient at the time of each comprehensive assessment. 3. Patient #4 had an admission date of 08/11/2022. Review of the clinical record revealed the following: a. The POC, dated 09/29/2024 to 11/27/2024, included orders for skilled nursing services and orders for medications. b. The DRR completed on 9/25/24, identified significant drug interactions, ineffective drug therapy, significant side effects, and noncompliance with drug therapy, but failed to identify duplicate medications of Lantus, (long acting insulin) and Jardiance, (oral hypoglycemic agent) (antidiabetic medications). The agency failed to address all 5 components of the DRR. The above findings were reviewed with the Administrator and the Clinical Manager. Findings include: According to agency policy, titled Drug Regimen Review Policy, dated 3/1/24, the drug regimen review includes compliance with drug therapy, significant side effects, drug interactions, ineffective drug therapy, duplicative drug therapy and drug reconciliation. During an interview on 11/14/24 at 8:32 AM, Clinical Manager, reported the RNs (registered nurses) utilize a report generated by the EMR (electronic medical record) that identifies drug interactions and duplicate medications, this was why the specifics regarding drug interactions and duplicate medications are not typed in the comment box on the drug regimen review document. During an interview on 11/14/24 at 9:31 AM, Staff C, Secretary, reported the agency is now able to get the EMR to show the list of drug interactions, duplicate medications, side effects and allergies to show on a report. Staff C instructed the surveyors on how to access this information. 1.Patient #1 had a start of care date of 11/1/24. Clinical record review revealed: a. Plan of Care, dated 11/1/24 to 12/30/24, included medication orders for acetaminophen and Tramadol (pain medications) and Plavix (clopidogrel) and aspirin (anticoagulants). b. Drug regimen review document, dated 11/1/24, identified the question are there any adverse side effects, drug interactions, duplicate therapy, ineffective drug or potential contradictions, marked yes. In the comment box: interactions only, see interaction flowsheet. c. Undated drug regimen review report identified no duplicate medications. The RN failed to identify the duplicate pain medications of acetaminophen and Tramadol, and the duplicate anticoagulant medications of Plavix (clopidogrel) and aspirin. 2. Patient #2 had a start of care date of 12/10/18. Clinical record review revealed: a. Plan of Care , dated 11/4/24 to 1/2/25, included medication orders for acetaminophen and Tramadol (pain medications) and Lantus (long-acting insulin) and Novolog (rapid-acting insulin) (antidiabetic medications). b. Drug regimen review document, dated 11/1/24, identified the question are there any adverse side effects, drug interactions, duplicate therapy, ineffective drug or potential contradictions, marked yes. In the comment box: see interaction review. The RN failed to identify the duplicate pain medications of acetaminophen and Tramadol, and the duplicate antidiabetic medications of Lantus and Novolog.”

“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 agency staff interview, clinical record review and agency policy review, the agency failed to administer drugs, services and treatment as ordered by the physician for 2 of 7 sampled patients (Patient’s #2 and #4). Failure to ensure staff obtain physician orders for administration of medications, services and treatments provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 2.Patient #4 had a start of care date of 8/11/22. Clinical record review revealed the following: a. The Plan of Care, (POC) dated 09/29/2024 to 11/27/2024, included physician orders for skilled nursing services and medications. b. The comprehensive assessment dated 9/25/24, revealed the patient utilized oxygen therapy during the night, and lymphedema leg pump therapy (compression pumps to aide in reduction of swelling) daily. The POC lacked any orders for oxygen or lymphedema pumps. c. During an interview with Staff B, Clinical Manager, on 11/14/24 at 8:30 AM, Staff B, Clinical Manager acknowledged the lack of physician orders for oxygen therapy and lymphedema pump therapy. d. The updated POC, dated 10/25/24, included home health aide frequencies for 1-2 times per week effective from 9/29/24. e. The signed physician order, dated 10/15/24, lacked specific frequency and duration for the home health aide visits. The clinical record lacked orders for treatments and services the patient was receiving. The above findings were reviewed with Administrator and the Clinical Manager. Findings include: According to the agency policy, titled Documentation Guidelines, dated 7/2024, drugs, services and treatments are administered only as ordered by a physician. 1.Patient #2 had a start of care date of 12/10/18. Clinical record review revealed: a. Plans of Care, dated 9/5/24 to 11/3/24 and 11/4/24 to 1/2/25, included physician orders for SN (skilled nurse) to change Dexacom continuous glucose monitor every 10 days and set up medications for the patient once weekly. b. Skilled nurse visit note, dated 10/6/24, identified the SN changed the Dexacom glucose monitor. c. Skilled nurse visit note, dated 10/17/24, identified the SN changed the Dexacom glucose monitor, 11 days after the last Dexacom change. d. Skilled nurse visit note, dated 10/27/24, identified the SN changed the Dexacom glucose monitor. e. Skilled nurse visit note, dated 11/7/24, identified the SN changed the Dexacom glucose monitor, 11 days after the last Dexacom change. f. Skilled nurse visit notes, dated 9/16/24, 10/14/24 and 10/28/24, identified the SN set up the patient’s medications for 2 weeks. During an interview on 11/14/24 at 8:32 AM, Clinical Manager, reported she contacted the SN who confirmed medications are being set up every other week for 2 weeks at a time, she did not write the order clearly to identify this. Clinical Manager confirmed the Dexacom had not been changed every 10 days as ordered. The skilled nurse failed to change the Dexacom glucose monitor every 10 days as ordered and set up medications weekly as ordered.”