Ace Home Care Network, Inc.

“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 record review and interview, the agency failed to ensure the comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 3 of 3 (P-1, 2, 3) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-1: The start of care (SOC) was dated 12/1/23, with diagnoses that included congestive heart failure and hypertension. During record review on 3/25/24, it was noted that the initial Comprehensive Assessment stated (under M2001 Drug Regimen Review), “Yes, issues found during review.” The medication profile documented “No issues found.” The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the issues found during the Comprehensive Assessment review. There was no explanation regarding the discrepancy in findings between the Comprehensive Assessment and the Medication Profile. P-2: The start of care (SOC) was dated 12/8/23, with diagnoses that included osteoarthritis, Type 2 diabetes mellitus with neuropathy, and muscle weakness. During record review on 3/25/24, it was noted that the initial Comprehensive Assessment stated (under M2001 Drug Regimen Review), “Yes, issues found during review.” The medication profile documented “Yes issues found.” The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the issues found during the comprehensive assessment review. P-3: The start of care (SOC) was dated 12/9/23, with diagnoses that included thrombocytopenia, failure to thrive, and hypertension. During record review on 3/26/24, it was noted that the initial Comprehensive Assessment stated (under M2001 Drug Regimen Review), “No issues found during review.” The medication profile documented “Yes issues found.” The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the issues found during the medication review. There was no explanation regarding the discrepancy in findings between the Comprehensive Assessment and the Medication Profile. During an interview on 3/26/24, the alternate clinical manager (Staff-2) acknowledged the above findings.”

“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 record review and interview, the agency failed to ensure the plan of care included objectively measurable goals specific to the individualized needs of the patient in 1 of 1 (P-1) records with Skilled Nursing services, from a total of 3 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-1: The start of care (SOC) was dated 12/1/23, with diagnoses that included congestive heart failure and hypertension. During record review on 3/25/24, it was noted that the Skilled Nursing goals on the Plan of Care were not measurable. One goal stated, “The patient/caregiver will verbalize understanding of individualized emergency plan by 12/23/2023.” Another stated, “Patient will verbalize an understanding of energy conserving measures by 12/15/2023.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 3/26/24 at 3:30 p.m., the alternate clinical manager (Staff-2) acknowledged the above findings.”