E P I C Home Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interview, the agency failed to ensure the plan of care included interventions with objectively measurable goals specific to the individualized needs of the patient in 1 (P-5) of 7 records reviewed, resulting in the potential for poor patient outcomes and unmet care needs for this patient. Findings include: P-5: This 82-year-old patient was admitted to home care on 8/3/24, with diagnoses of hypertensive heart disease and chronic kidney disease. During record review on 9/17/24, it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “patient will verbalize understanding of proper use of pain medication.” Another goal stated, “patient will verbalize an understanding of energy conserving measures.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. This finding was reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 a.m.”

“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 7 (P-1, 2, 3) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: Agency policy: Medication Profile; Policies and Procedures Manual (Revised March 2018) 11.8.1 states, “The comprehensive assessment performed at time of admission includes a review of all medications that 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, duplicative drug therapy and non-compliance with drug therapy. P-1: The start of care (SOC) was dated 11/17/23, with diagnoses of hypertensive heart disease with heart failure. During record review on 9/16/24, it was noted that the medication profile and the plan of care (POC) dated 11/17/23, documented Eliquis/Apixaban (Anticoagulant) oral 5 MG 1-tab 4X/day, and another order for Eliquis oral 5 MG 1-tab 2X/day. Albuterol Sulfate inhalation (2.5 MG/3ML) 0.083% HHN Q 4-6 ML as needed anti-asthmatic and bronchodilator, and another order for Albuterol Sulfate HFA inhalation 108 (90 Base) MCG/ACT 1-2 puffs every 4 hours as needed for chronic obstructive pulmonary disease (COPD) anti-asthmatic and bronchodilator. Pravastatin Sodium oral 10 MG 1 tab twice daily, and Pravastatin Sodium oral 10 MG 1 tab at bedtime. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. P-2: The SOC was dated 9/6/24 with diagnoses of osteoarthritis, weakness, and unsteady. During record review on 9/17/24, it was noted that the medication profile and the plan of care (POC) dated 9/6/24, documented Trelegy Ellipta inhalation 100-62.5-25 MCG/INH 1 puff daily listed twice. Pantoprazole Sodium oral 40 MG 1 tab daily was listed twice. Metoprolol Succinate ER oral 50 MG 1 tab daily, and Metoprolol Succinate ER oral 25 MG 1 tab daily. Atorvastatin Calcium oral 40 MG 1 tab daily at bedtime, and Atorvastatin Calcium oral 40 MG 1 tab daily. Amiodarone HCL oral 200 MG 1-tab oral daily was listed twice. Furosemide 40 MG oral 1 tab daily was listed twice. Eliquis/Apixaban (Anticoagulant) oral 5 MG 1 tab oral daily, Eliquis oral 5 MG 1 tab twice daily and Eliquis oral 2.5 MG 2 tabs patient to take one tablet twice daily orally. 3 separate orders for Eliquis were documented on the medication profile. The medication profile also documented Clopidogrel Bisulfate (Another anticoagulant) oral 75 MG 1 tab oral daily. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. During an interview on 9/19/24 at 1:30 p.m., the alternate administrator (Staff B), the clinical manager/registered nurse (Staff C), and the administrative assistant (Staff E) acknowledged the above findings. P-3: This 78-year-old patient was admitted to home care on 2/29/24 with diagnoses of wound on the toe, varicose veins, and peripheral vascular disease. During record review on 9/16/24, it was noted that the plan of care dated 2/29/24 contained multiple duplicate medications. For example, Xarelto 20mg was listed four times; 21 medications (vitamin E 1000U, vitamin C 500mg, fluconazole 100mg, melatonin 5mg, Claritin 10mg, hydrocodone 10/325mg, gabapentin 300mg, fenofibrate 200mg, esomeprazole 40mg, doxycycline 100mg, furosemide 20mg, digoxin 125 mcg, ropinirole 0.5mg, cilostazol 100mg, cholestyramine 4gm, cholecalciferol 10mg, Cartia XT 180mg, biotin 1000mcg, atorvastatin 10mg, allopurinol 100mg, and Synthroid 50mcg) were listed twice; and two medications (duloxetine 30mg and silver sulfadiazine 400gm) were listed once. This finding was reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 a.m. Staff B and Staff E stated they were unsure of why medications were populating multiple times on the plan of care while the medication profile listed medications once, and will be following up with the electronic medical record company. Agency policy: Medication Profile; Policies and Procedures Manual (Revised March 2018) 11.8.1 states, “The comprehensive assessment performed at time of admission includes a review of all medications that 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, duplicative drug therapy and non-compliance with drug therapy. P-1: The start of care (SOC) was dated 11/17/23, with diagnoses of hypertensive heart disease with heart failure. During record review on 9/16/24, it was noted that the medication profile and the plan of care (POC) dated 11/17/23, documented Eliquis/Apixaban (Anticoagulant) oral 5 MG 1-tab 4X/day, and another order for Eliquis oral 5 MG 1-tab 2X/day. Albuterol Sulfate inhalation (2.5 MG/3ML) 0.083% HHN Q 4-6 ML as needed anti-asthmatic and bronchodilator, and another order for Albuterol Sulfate HFA inhalation 108 (90 Base) MCG/ACT 1-2 puffs every 4 hours as needed for chronic obstructive pulmonary disease (COPD) anti-asthmatic and bronchodilator. Pravastatin Sodium oral 10 MG 1 tab twice daily, and Pravastatin Sodium oral 10 MG 1 tab at bedtime. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. P-2: The SOC was dated 9/6/24 with diagnoses of osteoarthritis, weakness, and unsteady. During record review on 9/17/24, it was noted that the medication profile and the plan of care (POC) dated 9/6/24, documented Trelegy Ellipta inhalation 100-62.5-25 MCG/INH 1 puff daily listed twice. Pantoprazole Sodium oral 40 MG 1 tab daily was listed twice. Metoprolol Succinate ER oral 50 MG 1 tab daily, and Metoprolol Succinate ER oral 25 MG 1 tab daily. Atorvastatin Calcium oral 40 MG 1 tab daily at bedtime, and Atorvastatin Calcium oral 40 MG 1 tab daily. Amiodarone HCL oral 200 MG 1-tab oral daily was listed twice. Furosemide 40 MG oral 1 tab daily was listed twice. Eliquis/Apixaban (Anticoagulant) oral 5 MG 1 tab oral daily, Eliquis oral 5 MG 1 tab twice daily and Eliquis oral 2.5 MG 2 tabs patient to take one tablet twice daily orally. 3 separate orders for Eliquis were documented on the medication profile. The medication profile also documented Clopidogrel Bisulfate (Another anticoagulant) oral 75 MG 1 tab oral daily. There was no documented clarification in the record as to which of these duplicate orders the patient should be taking. The medication profile signed by registered nurse (Staff C) also documented there were no discrepancies or interactions. During an interview on 9/19/24 at 1:30 p.m., the alternate administrator (Staff B), the clinical manager/registered nurse (Staff C), and the administrative assistant (Staff E) acknowledged the above findings. P-3: This 78-year-old patient was admitted to home care on 2/29/24 with diagnoses of wound on the toe, varicose veins, and peripheral vascular disease. During record review on 9/16/24, it was noted that the plan of care dated 2/29/24 contained multiple duplicate medications. For example, Xarelto 20mg was listed four times; 21 medications (vitamin E 1000U, vitamin C 500mg, fluconazole 100mg, melatonin 5mg, Claritin 10mg, hydrocodone 10/325mg, gabapentin 300mg, fenofibrate 200mg, esomeprazole 40mg, doxycycline 100mg, furosemide 20mg, digoxin 125 mcg, ropinirole 0.5mg, cilostazol 100mg, cholestyramine 4gm, cholecalciferol 10mg, Cartia XT 180mg, biotin 1000mcg, atorvastatin 10mg, allopurinol 100mg, and Synthroid 50mcg) were listed twice; and two medications (duloxetine 30mg and silver sulfadiazine 400gm) were listed once. This finding was reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 a.m. Staff B and Staff E stated they were unsure of why medications were populating multiple times on the plan of care while the medication profile listed medications once, and will be following up with the electronic medical record company.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained accurate clinical notes for 1 (P-3) of 7 records reviewed, resulting in the potential for poor patient outcomes and a lack of information for all agency staff caring for the patient. Findings include: P-3: This 78-year-old patient was admitted to home care on 2/29/24 with diagnoses of wound on the toe, varicose veins, and peripheral vascular disease. During record review on 9/16/24, it was noted that the nursing notes from 3/13/24, 3/20/24, and 3/25/24 contained identical comments for all three visit notes. For example, cardiovascular comments stated, “Patient has dried right leg venous ulcer, healed, concerns for very large bruise to right thigh, leg, increase in swelling and pain.” Musculoskeletal comments stated, “Patient reports walking exacerbates pain, in wheelchair today, concern for pressure to right back of thigh, instruct to shift weight, elevate legs through the day.” Psychosocial comments stated, “patient anxious about bruise to whole right upper thing in pain with lump of unknown cause, patient agitated.” Pain comments stated, “Patient reports taking Norco to help with pain in knees, and right hip.” Digestive nutrition comments stated, “encouraged to eat 3 meals a day and to incorporate protein into diet to promote wound healing. Encouraged not to skip meals, eating hardboiled egg.” These findings were reviewed and acknowledged by the alternate administrator (Staff B), the clinical manager (Staff C), and administrative support (Staff E) during an interview on 9/19/24 at 9:40 a.m. Staff B stated nursing notes are prefilled with prior comments to assist with continuity of care and stated staff should be updating the comments.”