Vitalcaring Group

“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 observations, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure staff reconciled patients’ medications for 2 (#1 and #2) of 3 (#1, #2 and #3) patients reviewed during home visits Review of the Agency’s Policy titled, “Medication List and Monitoring” dated May 2, 2024 revealed the following, in part: Purpose: To Outline a process for ongoing medication monitoring. Policy: The agency will maintain a current, accurate list of all prescription and over the counter medications taken by the patient. Patient #1 Review of the Clinical Record for Patient #1 revealed he began receiving services from the Home Health Agency on 11/07/2024 and had a current Certification Period of 11/07/2024 through 01/05/2025. Patient #1 had diagnoses, which included Chronic Kidney Disease with Heart Failure. A home visit was conducted with Patient #1 on 12/10/2024 at 9:30 a.m. with S3PTA present. Patient #1’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #1’s Current Medication Profile provided by the Home Health Agency: Fexofenadine 25mg one tablet daily was on the medication profile with a start date of 11/07/2024, which the patient was no longer taking. Nexletol 180mg one tablet daily was on the medication profile with a start date of 11/07/2024, which the patient was no longer taking. Amlodipine 10mg tablet one tablet daily was on the medication profile with start date of 11/07/2024, which the patient was no longer taking. An interview was conducted on 12/10/204 at 9:35 a.m. with Patient #1’s caregiver. She said Patient #1’s doctor changed the Amlodipine 10mg tablet one tablet daily to Amlodipine 5mg one tablet daily three weeks ago. She said Patient #1 stopped taking Fexofenadine 25mg and Nexletol 180mg three months ago. An interview was conducted on 12/10/2024 at 9:40 a.m. with S3PTA. S3PTA confirmed the above medication discrepancies identified during the home visit. S3PTA said medications should be reconciled during every home visit. Patient #2 Review of the Clinical Record for Patient #2 revealed he began receiving services from the Home Health Agency on 07/04/2024 and had a current Certification Period of 11/12/2024 through 12/30/2024. Patient #1 had diagnoses, which included Pulmonary Embolism. A home visit was conducted with Patient #2 on 12/10/2024 at 10:30 a.m. with S2RN present. Patient #2’s medications were reviewed during the home visit. The following medication discrepancy was identified when compared to Patient #2’s Current Medication Profile provided by the Home Health Agency: Eliquis 5mg tablet take one tablet twice a day was on the medication profile with a start date of 07/03/2024, which the patient was no longer taking. An interview was conducted on 12/10/204 at 10:35 a.m. with Patient #2. He said he had been taking Eliquis 10mg twice a day since 11/19/2024 per the doctor’s orders. An interview was conducted on 12/10/2024 at 10:40 a.m. with S2RN. S2RN confirmed the above medication discrepancy identified during the home visit. S2RN said medications should be reconciled during every home visit. An interview was conducted with S1DON on 12/10/2024 at 3:00 p.m. She was notified of the medication discrepancies identified during the home visits for Patient #1 and #2. She said each patients’ medications should be reconciled every discipline visit and staff should review the medication bottles each visit. She verified each patients’ Medication Profile should have reflected what the patient was currently taking.”

“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 record review and interview, the agency failed to ensure the Physician was notified regarding a change in a patient’s condition for 1 (#7) of 7 (#1- #7) patient records reviewed. The agency staff failed to timely communicate Patient #7’s abnormal urine culture result to the Physician. Findings: Review of Patient #7’s Clinical Record revealed she began receiving services with the agency on 12/05/2023 and had a certification period of 12/05/2023 through 02/02/2024. Patient #7 had diagnoses, which included Chronic Kidney Disease. Review of Patient #7’s faxed urine culture result received from the lab on 01/16/2024 revealed she had Escherichia Coli in her urine. Review of Patient #7’s Nurse’s Notes for certification period 12/05/2023 through 02/02/2024 revealed S1DON notified Patient #7’s doctor of the abnormal urine culture result on 01/18/2024. An interview was conducted on 12/09/2024 at 1:00 p.m. with S1DON. She said the agency received Patient #7’s urine culture and sensitivity result on 01/16/2024. She said Patient #7’s doctor was notified 01/18/2024. She said the staff should have ensured Patient #7’s doctor was notified on 01/16/2024 when the results were faxed from the lab to the agency. She said there was no effective process to ensure critical labs were reported to the doctor timely.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interviews, the agency failed to provide services that were ordered by the physician as indicated in the Plan of Care for 1 (#2) of 7 (#1 - #7) patients reviewed. The agency failed to ensure the skilled nurse obtained a weight or measured edema if unable to weigh every visit. Review of the agency’s policy titled “Orders for Care”, dated May 01, 2024, revealed the following, in part: Policy: To ensure patient care is provided in accordance with a Physician’s Order. Review of Patient #2’s Clinical Record revealed he began receiving services from the Home Health Agency on 07/04/2024 and had a current Certification Period of 11/12/2024 through 12/30/2024. Patient #1 had diagnoses, which included Pulmonary Embolism and Hypertensive Heart Disease with Heart Failure. Review of Patient #2’s Plan of Care for Certification Period 11/12/2024 through 12/30/2024 revealed Physician Orders which included the following, in part: Skilled Nurse to obtain weight or measure edema if unable to weigh every visit and notify Registered Nurse or the Medical Doctor of weight gain of three pounds in one day/five pounds within one week or significant changes in edema. Review of the Skilled Nurse visit notes for Patient #2 dated 11/06/2024, 11/13/2024 and 11/19/2024, 11/27/2024 and 12/04/2024 revealed no documented weight or measurement of edema. An interview was conducted on 12/10/2024 at 9:30 a.m. with S2RN. She confirmed she provided skilled nurse visits on the dates listed above and did not obtain Patient #2’s weight or measurement of edema. She said she usually just asked the patient what his last weight was from the previous doctor office visit. She confirmed according to Patient #2’s Plan of Care, weights or measurement of edema should have been obtained each nurse visit. An interview was conducted on 12/10/2024 at 3:30 p.m. with S1DON. She confirmed S2RN did not document Patient #2’s weight or measurement of edema each skilled nurse visit. She said S2RN should have obtained Patient #2’s weight or measurement of edema each visit as ordered by the Physician.”