Renville County Phns

“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, interview, and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 2 of 3 patients (P3, P5) whose medications were reviewed during home visits and record review. P3’s start of care (SOC) was 3/20/25. P3’s plan of care (POC) for certification period 3/20/25 to 5/18/25, included diagnoses of congestive heart failure (heart is unable to pump blood efficiently), atrial fibrillation (irregular heartbeat), peripheral vascular disease (narrowing or blockage of the blood vessels) and weakness. P3’s POC included orders for skilled nurse visits (SNV) one time per week for various assessments and evaluation which included to monitor vital signs, pain, and fall prevention interventions. SN to take International Normalized Ratio (INR) lab and coordinate results as well as medication reconciliation and education regarding management of diagnoses. P3’s medications were listed with medication name, dose, frequency and times. Medications included lisinopril 5 mg at bedtime, metoprolol 25 mg at bedtime, potassium 10 milliequivalents (mEq) in the morning, and spironolactone 25 milligrams (mg) one tablet in the morning. During a home visit conducted on 4/15/23, at 9:00 a.m. P3 stated she was not sure what medications she was taking. The assisted living staff set them up and administered the medications daily. P3’s current medication list at the assisted living facility was compared to the medications listed on P3’s POC as well as the agency’s current medication list generated on 3/24/25. The medications lisinopril, metoprolol in a 25 mg dose, potassium, and spironolactone were not listed as active medications on P3’s assisted living medication list or medication administration report dated April 2025, however the agency medication list and POC continued to identify these medications as active. During joint interview on 4/15/25, at 9:30 a.m. with P3’s case manager registered nurse (RN)-A and the assisted living manager who was the RN responsible to setup P3’s medications (RN)-C, RN-A stated the assisted living staff setup and administered P3’s medications daily. She was not aware P3’s spironolactone and metoprolol 25 mg had been discontinued. RN-C stated some medications had been discontinued on 3/25/25 and 3/31/25, and they discussed changes with the agency staff when they occurred. P5’s SOC was 2/11/25. P5’s POC for certification 4/12/25 through 6/10/25, included diagnoses cerebral infarction (stroke), diabetes, hypertension (high blood pressure) and anxiety disorder. Orders included SNV one time per month for observation and assessment of condition, mobility, transition to assisted living, fall risk and coordination of services. P5’s medications were listed with medication name, dose, frequency and times. Medications included insulin Aspart 4 units subcutaneously (SQ) in the morning, 8 units at noon and 6 units in the pm daily, insulin glargine 36 units at bedtime, and metoprolol (for high blood pressure) 50 mg two times per day. During a home visit conducted on 4/15/23, at 3:30 p.m. P5 stated she was not sure of all the medications she was taking, however, knew she took insulin and metoprolol. The assisted living staff set them up and administered the medications daily. The occupational therapist (OT)-A stated the assisted living setup and administered P5’s medications daily. OT-A completed a medication review with the patient at every visit. OT-A updated the patient’s RN case manager if or when any changes or concerns were noted with a patient medication. P5’s current medication list at the assisted living facility was compared to the medications listed on P5’s POC and agency’s current medication list generated on 4/15/25. Medication changes were identified on the assisted living medication list which included insulin glargine increased to 40 units at bedtime and vitamin C was ordered on 2/19/25. Aspart insulin was noted to have been increased to 6 units in the am, and 10 units at noon and evening and P5’s metoprolol was increased to 75 mg in the am on 3/5/25 at the assisted living, however the changed medications were not identified on the agency’s medication list or POC. When interviewed on 4/15/25, at 1:00 p.m. P5’s case manager, RN-A stated P5 was mostly on agency services for therapy, and it was difficult to keep the medication list accurate and up to date with therapy only cases. During interview on 4/16/25, at 2:13 p.m. the clinical manager (CM)-A stated staff were expected to review a patient’s medications for any changes every visit and obtain physician verbal orders as well as update of the patient’s medication lists. Medication lists needed to be accurate at all times so providers and staff were aware of exactly what the patient was taking at all times. The agency policy Medication Management dated 6/1/14, identified the individualized medication management plan would be addressed on the POC and reassessed every 60 days or as needed for change of status or new physician orders. Patient response to medications would be assessed on each home visit.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on observation, interview and document review the agency failed to revise the plan of care (POC) to reflect all current on-going orders for services received during the 60-day period for one of seven patients (P5) reviewed for home care services. P5’s SOC was 2/11/25. P5’s POC for certification 2/11/25 to 4/11/25, included diagnoses cerebral infarction (stroke), diabetes, hypertension (high blood pressure) and anxiety disorder. Orders included SNV one time per month for various observation and assessment, physical therapy (PT) one time per week for one week for continuing visits to improve mobility, strength, endurance and reduce risk for falls and occupational therapy (OT) one time per week for one week for continuing exercises. P5’s SOC was 2/11/25. P5’s POC for certification 4/12/25 through 6/10/25, P5’s SOC was 2/11/25. P5’s POC for certification 4/12/25 through 6/10/25, included diagnoses cerebral infarction, diabetes, hypertension and anxiety disorder. Orders included SNV one time per month for various observation and assessment, PT one time per week for one week for continuing visits and OT one time per week for one week for continuing exercises. During a home visit conducted on 4/15/23, at 3:30 p.m. P5 stated she received PT, OT and nurse visits from the agency. The occupational therapist (OT)-A was observed directing P5 through various exercises and stated she assisted P5 with strengthening exercise weekly. Review of P5’s medical record identified the following: P5 was seen by OT every week 2/12/25 through 4/9/25. P5 was seen by PT every week 2/12/25 through 4/7/25. During interview on 4/15/25, at 1:30 p.m. the administrative staff (AS)-B stated therapy sent in their own orders to the physician for services and then sent the orders to the agency. When AS-B received the orders, she made a copy for the case manager. The case manager was responsible to follow up to make sure all orders had been obtained and the POC was updated. When interviewed on 4/15/25, at 2:00 p.m. RN-B stated therapy was responsible for getting the order for services signed by the physician. P5’s orders had not been signed and returned. She had not updated P5’s second recertification POC to include the therapy services P5 was receiving and P5’s medical record lacked orders to reflect therapy services she was receiving. When interviewed on 4/16/23, at 1:36 p.m. the clinical manager (CM)-A stated the agency nurses should follow up weekly to ensure all orders were completed and update the POC with any changes. The primary nurse should have definitely been aware of what therapy services P5 received by the time she had completed P5’s second recertification period and should have obtained current orders for all services, as well as revised the POC. The facility policy Therapy Services dated 6/1/14, identified therapists should provide services as determined by assessments and as per physician orders. The therapist would consult and collaborate with the RN case manager and participate in implementing the physician’s plan of care.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and document review, the agency failed to ensure physician orders were obtained for therapy visits were initiated following start of care, as well as when the services were continued into another certification period for 1 of 7 patients (P5) reviewed in the sample. P5’s SOC was 2/11/25. P5’s POC for certification 2/11/25 to 4/11/25, included diagnoses cerebral infarction (stroke), diabetes, hypertension (high blood pressure) and anxiety disorder. Orders included SNV one time per month for various observation and assessment, physical therapy (PT) one time per week for one week for continuing visits to improve mobility, strength, endurance and reduce risk for falls and occupational therapy (OT) one time per week for one week for continuing exercises. P5’s SOC was 2/11/25. P5’s POC for certification 4/12/25 through 6/10/25, P5’s SOC was 2/11/25. P5’s POC for certification 4/12/25 through 6/10/25, included diagnoses cerebral infarction, diabetes, hypertension and anxiety disorder. Orders included SNV one time per month for various observation and assessment, PT one time per week for one week for continuing visits and OT one time per week for one week for continuing exercises. During a home visit conducted on 4/15/23, at 3:30 p.m. P5 stated she received PT, OT and nurse visits from the agency. The occupational therapist (OT)-A was observed directing P5 through various exercises and stated she assisted P5 with strengthening exercise weekly. Review of P5’s medical record identified the following: On 2/12/25, an initial evaluation was completed by OT with a plan for continued visits one time per week for four weeks. P5’s medical record lacked documentation of signed physician orders for the anticipated visits. On 3/26/25, a reassessment visit was completed by OT with a plan for continued visits one time per week for four weeks. P5’s medical record lacked documentation of signed physician orders for the anticipated visits. P5 was seen by OT every week 2/12/25 through 4/9/25. On 2/12/25, an initial evaluation was completed by PT with a plan for continued visits two times per week for one week then one time per week for three weeks. P5’s medical record lacked documentation of signed physician orders for the anticipated visits. On 3/12/25, a 30-day assessment was completed by PT with a plan for continued visits one time per week for four more weeks. P5’s medical record lacked documentation of signed physician orders for the anticipated visits. On 4/7/25, a 60-day assessment was completed by PT with a plan for continued visits one time per week for one more week. P5’s medical record lacked documentation of signed physician orders for the anticipated visits. P5 was seen by PT every week 2/12/25 through 4/7/25. During interview on 4/15/25, at 1:30 p.m. the administrative staff (AS)-B stated therapies sent in their own recertification orders for the physician to sign and sent the agency a copy. AS-B double checked with P5’s case manager registered nurse (RN)-B who told her she had reached out several times to the therapy department regarding the need for signed therapy orders and still had not received them. When interviewed on 4/15/25, at 2:00 p.m. RN-B stated therapy was responsible to send their orders to the physician and to the primary nurse. Sometimes verbal orders were written when the nurse received therapy certification notes but not always. RN-B was unable to find any signed physician orders for physical or occupational therapy for P5. RN-B thought part of the problems was the physician was not a local one and so the agency orders may not be a priority. RN-B had completed P5’s recertification when it came due and had failed to include occupational and physical therapy in the POC and she should have had the frequency, duration and summary of services the therapies had planned to provide. During interview on 4/16/23, at 1:36 p.m. the clinical manager (CM)-A stated it was the agency’s past practice to send verbal orders for all therapy services but the agency home care liaison for therapy had stated she would ensure all therapy orders were obtained when needed and did not want the agency to do duplicate work. Agency nurses were expected to follow up weekly to ensure all orders were completed. At minimum the lack of therapy orders should have been identified when the second recertification had been completed. On 4/16/25, at 1:52 p.m. during telephone interview with physical therapy manager (PTM)-C, PTM-C stated therapy sent their orders for services to the physicians and follow up on them at least every other day. The therapists were pretty aggressive about making sure they had all their required orders for services. PTM-C could not imagine there were no signed therapy orders for P5, and he would have to look into the issue and fax the home care agency. The agency policy Therapy Services dated 6/1/14, identified therapist would provide services as determined by assessments and as per physician orders. Physician orders would be obtained for the kind, type and intensity of therapy services. After the assessment was completed, the therapist would communicate specific treatments and modalities to be used and would obtain the verbal order from the physician for the specific modalities.”