Franklin County Public 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 home visit observations, patient interviews, staff interviews, clinical record reviews and agency policy review, the agency failed to perform complete an accurate drug regimen reviews with each comprehensive assessment and identify patient specific medication issues for 3 of 3 sampled patients with home visit observations (Patients #1, #2 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: 3.Patient #2 had a start of care date of 7/24/23. Clinical record review revealed the following: a. The POCs, dated 7/18/24 to 9/15/24 and 9/16/24 to 11/14/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 9/11/24, completed by Staff C, RN, identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/29/24 at 8:00 AM, with Staff C, RN, an interview with Patient #2 revealed the patient sets up his/her own medication. The patient identified the following medication discrepancy: The patient identified he/she takes Iron 65mg (supplement) one tablet every day and has done so for at least one year. The POC lacked documentation of an order for Iron. The above findings were shared with the Administrator and Clinical Manager. According to the undated agency policy titled Medication Profile, the nurse shall record on the medication profile all prescribed and over-the-counter medications the client is currently taking. The medication profile shall be reviewed by a Registered Nurse (RN) at least weekly or with every visit if patient is seen less often than weekly and updated whenever there is a change or discontinuation in medication. During an interview on 10/30/24 at 8:25 AM the Clinical Manager stated the drug regimen review (DRR) completed at all assessment time points, start of care, recertification, resumption of care , significant changes and at discharge. 1.Patient #1 had a start of care date of 2/8/24. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 8/6/24 to 10/4/24 and 10/5/25 to 12/3/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 10/1/24, completed by Staff B, Clinical Manager, identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/29/24 at 2:30 PM, with Staff B, Clinical Manager, interview with Patient #1 revealed the nurse sets up his/her own medication. The patient identified the following medication discrepancies: 1)The patient identified he/she took melatonin (sleep aid) 5 milligrams (mg) at hour of sleep as needed. The POC lacked documentation of an order for melatonin. The patient stated the medication taken for a couple of months. 2. Patient #3 had a start of care date of 6/24/21. Clinical record review revealed the following: a. The POCs, dated 8/7/24 to 10/5/24 and 10/6/25 to 12/4/24 included physician orders for medications and skilled nursing services. b. The recertification comprehensive assessment, dated 10/3/24, completed by Staff C, RN, identified a DRR was completed and no changes were made to medications. c. During a home visit observation on 10/29/24 at 10:30 AM, with Staff C, RN, interview with Patient #3 revealed the patient sets up his/her own medication. The patient identified the following medication discrepancies: 1) The patient identified he/she took an Albuterol inhaler every 4 to 6 hours as needed. The POC lacked documentation of an order for albuterol inhaler. The albuterol filled on 8/14/24. 2) The bottle of furosemide (diuretic) dated 9/17/24, included orders to take 20 mg daily and 1 tablet as needed for swelling. The POC identified an order for furosemide 20 mg daily and lacked an order for 1 tablet as needed for swelling. 3) The bottle of calcium with vitamin D (supplement) identified a dosage of calcium 600 mg and vitamin D 20 micrograms (mcg). The POC failed to include the dosage of the ordered medication.”

“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 home visit observations, patient interviews, clinical record reviews and policy reviews, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment used by the patient and information related to advanced directives for 2 of 3 sampled patients with home visit observations (Patients #1 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed patients at risk to not receive services, medications, supplies and/or treatments according to assessed needs and physician orders. Findings include: 2. Patient #1 had a start of care date of 2/8/24. Clinical record review revealed the following: a. The POCs, dated 8/6/24 to 10/4/24 and 10/5/24 to 12/3/24, included the following durable medical equipment (DME) and supplies used by the patient: medication planners and diabetic testing supplies. b. During a home visit observation on 10/29/24 at 2:30 PM, with Staff B, Clinical Manager, the surveyor identified the following DME in the home: glucometer. The POC failed to include the DME of a glucometer. 3. Patient #3 had a start of care date of 6/24/24. Clinical record review revealed the following: a. The POCs, dated 8/7/24 to 10/5/24 and 10/6/24 to 12/4/24, included the following durable medical equipment (DME) and supplies used by the patient: shower chair and walker. b. During a home visit observation on 10/29/24 at 10:30 AM, with Staff E, RN, the surveyor identified the following DME in the home: grab bars, toilet riser, medication planners, lifeline and lift chair. The POC failed to include the DME of grab bars, toilet riser, medication planner, lifeline and lift chair. The above findings shared with the Administrator and Clinical Manager. According to the undated agency policy titled Plan of Care, the Plan of Care (POC) is based on current assessment by a Registered Nurse. The client or caregiver will actively participate in developing the POC and the POC will be reviewed by the physician at least every 60 days. The POC should include but is not limited to: All pertinent diagnosis (es), type, frequency and duration of visits/services, medications, treatments and procedures, treatment goals and other appropriate items. Professional staff will promptly alert the physician to any changes that suggest a need to alter the POC. 1.Patient #2 had a start of care date of 7/24/23. Clinical record review revealed the following: a. The POC, dated 9/16/24 to 11/14/24 included the following durable medical equipment (DME) and supplies used by the patient: Cane, commode, home oxygen, incentive spirometer, nebulizer, shower chair, walker, wheelchair and wheelchair cushion. b. During a home visit observation on 10/29/24 at 8:00 AM, with Staff C, Registered Nurse (RN), the surveyor identified the following DME in the home: ramp, motorized scooter, pill cutter, hand held shower, grab bars and toilet safety frame. During the same visit, an interview with Patient #2 revealed he/she had been utilizing the ramp, motorized scooter, pill cutter, hand held shower, grab bars and toilet safety frame for more than 1 year. c. The POC, dated 9/16/24 to 11/14/24, identified the patient’s Advanced Directives as: Do not resuscitate, full code, living will. On 10/29/24 at 8:30 AM, during an interview, Patient #2 identified he/she has been a full code (wants resuscitative measures) for greater than 6 months. The POC failed to include the DME of ramp, motorized scooter, pill cutter, hand held shower, grab bars and toilet safety frame and the POC failed to include accurate advanced directives for the patient.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on agency staff interviews, clinical record reviews and policy reviews, the agency failed to complete and send a transfer summary to physician caring for the patient at the inpatient facility within 2 business days of a planned transfer for 1 of 2 sampled patients with transfers/discharges (Patient #2). Failure to send the physician and other health care professionals a summary of the patient’s care while receiving services from the agency in a timely manner increases the risk for inadequate or inappropriate follow-up during inpatient care. Findings include: According to the undated agency policy, titled Client Transfer Process, a client may be transferred as determined by the agency director or designated Registered Nurse (RN) in response to an identified need that cannot be met by the agency. If a client is transferred to another health facility, a copy of the record shall be faxed to the receiving facility. During an interview on 10/30/24 at 8:25 AM, Staff B, Clinical Manager identified a transfer summary must be sent to the facility the patient was transferred to within 48 hours. If the transfer summary is not sent within 48 hours, there must be documentation indicating the reason for lack of timeliness. Patient #2 had a start of care date of 7/24/23. Clinical record review revealed the following: a. A home health transfer summary completed by Staff C, RN, dated 8/2/24, included documentation Staff C advised patient to go to the emergency department due to a decline in condition. b. Hospital discharge records identified the patient was hospitalized from 7/29/24 to 8/5/24. The agency failed to send a transfer summary to the hospital within 2 business days of a planned transfer. The above findings were reviewed with the Administrator and Clinical Manager.”