Beacon Home 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 record review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to determine any duplicate therapy or adverse effects, failed to ensure the Registered Nurse provided oversight of the review process, and failed to ensure the physician was notified of potential drug interactions or duplicate therapy in 6 of 13 (P-3, 5, 13, 6, 7, and 8) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-6: This 93-year-old patient was admitted to the agency on 1/27/24 with diagnoses which included prostate cancer; bone cancer; and pneumonia. The medical record was reviewed on 2/6/24. During review of the Comprehensive Assessment dated 1/27/24, it was noted the registered nurse (RN) completing the drug regimen review checked the box indicating that no significant medication issues were found. Using the agency’s medication interaction software, a medication interaction report was generated on 2/6/24. The report noted 2 duplicate medication therapies. There was no documentation in the medical record that the RN became aware of the duplicate medication therapies, and no documentation that the physician was notified of the duplicate therapies. P-7: This 72-year-old patient was admitted to the agency on 1/15/24 with diagnoses which included spondylosis of lumbosacral region of spine (deterioration of joints and cartilage in low back) and spinal stenosis (condition where spinal column narrows). The medical record was reviewed on 2/7/24. The Plan of Care dated 1/15/24 contained orders for physical therapy (PT) services only. During review, it was noted that the PT completed and signed the Comprehensive Assessment (including drug regimen review) on 1/15/24. The PT also completed and signed the Patient Medication Record on 1/16/24. There was no documentation that an RN did an assessment of the patient’s medications. P-8: This 69-year-old patient was admitted to the agency on 4/21/23 with diagnoses which included low blood pressure; pancytopenia (low levels of all blood cells in body); and schizophrenia. The medical record was reviewed on 2/7/24. During review of the Comprehensive Assessment dated 4/21/23, it was noted the RN completing the drug regimen review checked the box indicating that no significant medication issues were found. Using the agency’s medication interaction software, a medication interaction report was generated on 2/7/24. The report noted 3 duplicate medication therapies. There was no documentation in the medical record that the RN became aware of the duplicate medication therapies, and no documentation that the physician was notified of the duplicate therapies. The above findings were reviewed and acknowledged during interview on 2/8/24 at 2:00 pm with the Administrator (Staff A) and Alternate Administrator (Staff B). Staff B viewed the above patient’s medication profiles and used the agency medication interaction software to identify duplicate therapies. Staff B noted that duplicate therapies were described in the report and stated that staff had not been including medications found to be duplicate therapies when doing the medication interaction review. Agency Policy 10.0: Medications (1997-2001, Rev 2.0) The registered nurse assesses medications the patient is taking to identify ineffective drug therapy, potential adverse reactions, significant side effects and drug interactions, duplicative drug therapy, noncompliance with drug therapy and any high-alert medications and notifies the physician promptly. P-3: This 88-year-old patient was admitted to home care on 1/4/24 with diagnoses of stroke with hemiplegia (muscle weakness or partial paralysis) and dysphagia (difficulty swallowing), and pelvic fracture. During record review on 2/5/24, it was noted that the start of care assessment dated 1/4/24 stated no issues found during drug regimen review. A medication interaction report was generated, using the agencies electronic medical record (EMR) software that indicated drug allergy alert for Hydrocodone as the patient is allergic to codeine and for Tamsulosin as patient is allergic to sulfa. This report also indicated duplicate drug therapy with Acetaminophen and Hydrocodone. There was no evidence that the physician was notified of the allergies or the duplicate drug therapy. P-5: This 69-year-old patient was admitted to home care on 1/9/24 with diagnoses of surgical aftercare post right ankle and subtalar joint arthrodesis, and type 2 diabetes. During record review on 2/6/24, it was noted that the start of care assessment, completed by the physical therapist, dated 1/9/24, stated no issues found during drug regimen review. A medication interaction was generated, using the agencies EMR software that indicated a drug allergy alert for Paxil as the patient is allergic to Cymbalta. This report also indicated duplicate therapy with amlodipine and Losartan HCTZ. During joint survey home visits with the PTA/RN on 2/7/24 at 10:00 a.m., a medication reconciliation was conducted with the patient. In addition to the medications listed in the plan of care, the patient states she is also taking Atorvastatin, pramipexole, Celebrex, and Ozempic. These four medications were listed in history and physical records (dated 12/28/23) and discharge notes from her stay during rehab (dated 1/1/24). There was no evidence that a registered nurse assessed medications as indicated in the agency policy, no evidence that the physician was notified of the allergy or duplicate drug therapy, or that these four additional medications were assessed for potential interactions. P-13: This 86-year-old patient was admitted to home care on 1/5/24 with diagnoses hypertensive heart disease, chronic diastolic heart failure, chronic kidney disease, and anemia. During record review on 2/7/24, it was noted that the start of care assessment dated 1/5/24 stated no issues found during drug regimen review. A medication interaction report was generated, using the agencies EMR software that indicated drug allergy alert for Tramadol as the patient is allergic to hydromorphone. This report also indicated duplicate drug therapy with metoprolol and torsemide. There was no evidence that the physician was notified of the allergy or the duplicate drug therapy. These findings were reviewed and acknowledged by the administrators (Staff-A & B), the clinical manager (Staff-C), and the alternate clinical manager (Staff-D) during an interview on 2/8/24 at 1 p.m.”

“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 individualized, patient-specific, measurable outcomes and goals in 7 of 13 (P-1, 2, 3, 4, 13, 6, and 7) sampled records reviewed potentially resulting in insufficient information to adequately assess patient progress. Findings include: P-1: This 78-year-old patient was admitted to home care on 12/15/23, with diagnoses of congestive heart failure, aortic valve insufficiency, and sick sinus syndrome. During record review on 2/5/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “patient and caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by end of episode” and “patient/caregiver demonstrates understanding of CHF and self-management skills to prevent re-hospitalization.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-2: This 86-year-old patient was admitted to home care on 1/21/23, with diagnoses of type 2 diabetes, essential hypertension, and malnutrition. During record review on 2/5/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “patient and caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by end of episode” and “patient/caregiver effectively manages all aspects of diabetic care.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-3: This 88-year-old patient was admitted to home care on 1/4/24 with diagnoses of stroke with hemiplegia (muscle weakness or partial paralysis) and dysphagia (difficulty swallowing), and pelvic fracture. During record review on 2/5/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “patient and caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by end of episode” and “patient/caregiver verbalizes understanding of start of care instructions.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-4: This 70-year-old patient was admitted to home care on 10/11/23 with diagnoses of post procedure (hernia repair) seroma, and pain. During record review on 2/5/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “patient and caregiver will verbalize understanding of medication regimen, dose, route, frequency, indications, and side effects by end of episode” and “patient/caregiver will demonstrate understanding of complications to report.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. P-13: This 86-year-old patient was admitted to home care on 1/5/24 with diagnoses hypertensive heart disease, chronic diastolic heart failure, chronic kidney disease, and anemia. During record review on 2/7/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. The plan of care contained the following goals, “patient is compliant with medication regime” and “patient/caregiver demonstrates understanding of CHF and self-management skills to prevent re-hospitalization.” There was no evidence of how these could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrators (Staff-A & B), the clinical manager (Staff-C), and the alternate clinical manager (Staff-D) during an interview on 2/8/24 at 1 p.m. P-6: This 93-year-old patient was admitted to the agency on 1/27/24 with diagnoses which included prostate cancer; bone cancer; and pneumonia. The medical record was reviewed on 2/6/24. The Comprehensive Assessment completed on 1/27/24 included documentation of the patient’s pain status. The patient’s pain level (relating to the cancer diagnoses) was described as chronically 8 out of 10 (where 0 is no pain and 10 is the worst pain) before pain medication and, the patient’s goal for pain was 0-1. During record review of the plan of care (POC) dated 1/27/24, it was noted that two services had completed an assessment with outcomes and goals of care, skilled nursing (SN) and physical therapy (PT). In the SN outcomes and goals section of the POC, it was noted that the SN documented, “pain is controlled” and had no goals listed for pain management. The PT outcomes and goals section also did not include a goal for pain management. During a joint surveyor home visit on 2/7/24 at 1:00 p.m., the patient was noted to have recently begun a new pain medication and the patient’s caregiver stated the new medication was to have better control over the patient’s pain. There were no individualized, patient-specific, measurable outcomes or goals related to the management of this patient’s pain. P-7: This 72-year-old patient was admitted to the agency on 1/15/24 with diagnoses which included spondylosis of lumbosacral region of spine (deterioration of joints and cartilage in low back) and spinal stenosis (condition where spinal column narrows). The medical record was reviewed on 2/7/24. The Comprehensive Assessment completed on 1/15/24 included documentation of the patient’s pain status. The patient’s pain level was described as chronically 7 out of 10 before pain medication and, pain affected sleep and day to day activities almost constantly. The patient’s pain goal was left blank in the Comprehensive Assessment. During record review of the POC dated 1/15/24, the only goal and outcome listed for pain included the following: Pain that interferes with patient’s activity or movement will be reduced, Target Date: 3/14/24. It was unclear what the patient-specific goal for pain was or how this goal would be objectively measured to determine progress. The above findings were reviewed and acknowledged during interview on 2/8/24 at 2:00 pm with the Administrator (Staff A) and Alternate Administrator (Staff B).”

“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 interview, the agency failed to ensure the registered nurse provided services as ordered by the physician in the plan of care for 2 of 13 (P-1, 13) records reviewed, resulting in the potential for physical decline and unmet care needs for these patients. Findings include: P-1: This 78-year-old patient was admitted to home care on 12/15/23, with diagnoses of congestive heart failure, aortic valve insufficiency, and sick sinus syndrome. During record review on 2/5/24, it was noted that the plan of care orders clinicians to “notify the physician of weight greater than 164 pounds or less than 154 pounds.” On admission, the patient’s weight was documented at 159 lbs. There was no evidence of weight documentation on the skilled nursing visit week 2 (12/18/23), week 5 (1/9/24), or week 6 (1/16/24). P-13: This 86-year-old patient was admitted to home care on 1/5/24 with diagnoses hypertensive heart disease, chronic diastolic heart failure, chronic kidney disease, and anemia. During record review on 2/7/24, it was noted that the plan of care orders clinicians to “notify the physician of weight greater than 180 pounds or less than 170 pounds.” On admission, the patient’s weight was documented at 175 lbs. On 1/18/24, the patient’s weight was documented as 182 lbs. and the nurse documented, “weight stable and unchanging from last visit, pt (patient) asymptomatic.” There was no evidence the physician was notified. These findings were reviewed and acknowledged by the administrators (Staff-A & B), the clinical manager (Staff-C), and the alternate clinical manager (Staff-D) during an interview on 2/8/24 at 1 p.m.”

“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 record review and interview, the agency failed to ensure a detailed discharge summary was sent to the physician within 5 business days of discharge for 1 of 4 (P-1) discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-1: This 78-year-old patient was admitted to home care on 12/15/23, with diagnoses of congestive heart failure, aortic valve insufficiency, and sick sinus syndrome. During record review on 2/5/24, it was noted that the patient was discharged from agency services on 1/23/24. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. This finding was reviewed and acknowledged by the administrators (Staff-A & B), the clinical manager (Staff-C), and the alternate clinical manager (Staff-D) during an interview on 2/8/24 at 1 p.m.”