Lhc-Illinois Home Health Care

“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 observation, document review and interview, it was determined for 2 of 5 (Pt #3 and Pt #5) patients, where home visits were conducted, the Home Health Agency (HHA) failed to visualize all medications and compare them to the current medication profile to ensure the patient was taking the correct medication(s). Findings include: 1. On 5/14/2024 at 11:00 AM, a home visit was conducted at Pt #3’s residence. SOC (Start of Care) 4/14/2024, diagnosis: hemiplegia following cerebral infarction affecting left nondominant side. At no time was the Physical Therapist (E #3) observed visualizing the patient’s medication bottles to ensure they matched the current medication profile, ensuring proper medication administration and accurate medication profile. The following discrepancies were noted: a. Lisinopril 10 mg was not on medication list (Pt #3 reports he has been taking this medication for 2 years). b. Hydrochlorothiazide 12.5 mg was not on medication list (Pt #3 reports he has been taking this medication for 3 years). 2. On 5/15/2024 at 2:30PM, a home visit was conducted at Pt #5’s residence. SOC 4/13/2024, diagnosis: displaced intertrochanteric fracture of femur. During the home visit the Occupational Therapist (E #2) was observed reviewing the patient’s medications via an electronic tablet, no medication list was observed in the patient’s home. The following discrepancies were noted: a. Toprol XL 50 mg tablet Extended Release (ER) listed on agency medication list. A bottle of Metoprolol ER Succinate 100mg tablets was observed on patient’s kitchen counter. Patient #5 stated she has been taking Metoprolol ER Succinate 100mg dosage since 4/11/2024. b. The following medications were listed on the agency’s medication profile for Pt #5, but the patient reports she was instructed not to take them when she was discharged from the hospital on 4/11/2024: Acetaminophen 500mg tablet, Amlodipine 2.5mg tablet, Fosamax 70mg tablet, Gabapentin 300mg capsule, lisinopril 20mg tablet, Lovastatin 20mg tablet, Melatonin 3mg tablet, Miralax 17 gram oral powder packet, and Senna Laxative 8.6mg tablet. 3. On 5/14/2024 at approximately 3:30 PM, the policy “Monitoring Medications” (revised 12/01/23), was reviewed. Under “Procedure:...2.” the policy noted, “During the patient’s episode of care the following will occur: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies;” 4. On 5/16/2024 at approximately 10:00 AM, an interview was conducted with Executive Director (E #1). E #1 reviewed Pt #3 and Pt #5’s medication record and verbally agreed with the above findings. E #1 stated, “Our standard is to physically observe patient’s medication bottles and compare to medication list every visit.””

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on document review and interview it was determined for 1 of 2 (pt #3) patients records reviewed who had falls, the Agency failed to ensure the physician was notified of the change in the patient’s condition. Findings include: 1. Pt #3 SOC: 4/14/2024 Diagnosis: hemiplegia following cerebral infarction affecting left nondominant side. The record was reviewed on 5/13/2024 at approximately 2:15 PM. The Client Coordination Note Report written by Registered Nurse (E# 4), dated 4/20/2024, noted “…Reports sliding out of the bed at some point this week and landing on the carpet in his room no injuries noted his son picked him up off the floor”. The record lacked documentation the physician was notified of Pt #3’s fall, as of 5/13/2024. 2. On 5/13/2024 the policy “Patient Fall Reduction Program” (revised 10/01/23) was reviewed at approximately 3:45 PM. The policy noted, “…Procedure:…Patient Falls…c. All patient falls, un-witnessed, staff witnessed, or non-staff witnessed, are entered as an occurrence in the Online Reporting System.” 3. An interview was conducted on 5/13/2024 at 3:30 PM with the Executive Director (E #1). E #1 reviewed Pt # 3’s chart and verbally agreed the record lacked documentation the physician was notified of Pt #3’s fall. E #1 stated, “When a fall happens, the provider should make an occurrence in the patient’s record and the physician should be notified.” There is a box on the Client Occurrence Report that should be checked when the physician is notified.”