Lifecare Medical Center

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and document review, the agency failed to update their emergency plan at least every two years as required. Findings include: On 8/8/24, the agency’s emergency preparedness plan was reviewed. The agency’s emergency preparedness plan communication call list and staffing list was outdated and listed staff members who no longer were employed by the agency. The last recorded review date was identified as May, 2014. During interview on 8/8/24, registered nurse (RN)-C stated the director of home care usually attended the emergency preparedness meetings and exercises and then brings the information back to the rest of the staff. The campus wide emergency plan was updated; however, the agency’s book had not been reviewed recently. The agency’s Emergency Operations Plan policy dated 5/14, identified the communication plan would be developed, maintained and revised as needed and in compliance with applicable local, state, and federal regulations.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure each patient had an initial assessment visit within 48 hours of the referral date for 1 of 7 patients (P1) reviewed, in the sample. Findings include: P1’s plan of care (POC) 7/24/24 to 9/21/24, identified a start of care (SOC) 3/26/24, with diagnoses which included schizoaffective disorder, bipolar type, post-traumatic stress disorder, insomnia, anxiety, depression and diabetes. Services included skilled nurse visits (SNV) one time per week to assess and evaluate home safety needs, fall prevention, abuse prevention and medication management. P1’s medical record identified a referral for home care services on 3/22/24. P1’s SOC assessment visit was not completed until 3/26/24. P1’s medical record failed to identify any reason P1 had not been assessed within 48 hours of the referral date of 3/22/24, and lacked evidence P1’s physician was notified of the delay in the SOC date. When interviewed on 8/7/24, at 3:30 p.m. registered nurse (RN)-A stated the agency had attempted to contact P1 on 3/22/24, after they received the referral but had not been able to reach him. The following Monday they realized they had the wrong phone number. They got the correct contact number and admitted him the next day. RN-A was not able to find documentation P1’s primary physician had been notified of the delay in start of care. It was the agency’s practice to notify the client’s primary physician when a home care admission could not occur on the day it was ordered. The agency policy Client Evaluation, Assessment, and Re-assessment Visits dated 7/18, identified registered nurses would attempt to contact by telephone or visit every client referred for skilled and maintenance services within 48 hours of referral or within 48 hours of the client’s return to home or on the physician ordered start date.”

“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 7 clients (P1, P3) whose medications were reviewed during home visits or record review. Findings include: P1’s plan of care (POC)7/24/24 to 9/21/24, identified a start of care (SOC) 3/26/24, with diagnoses which included schizoaffective disorder, bipolar type, post-traumatic stress disorder, insomnia, anxiety, depression and diabetes. Services included skilled nurse visits (SNV) one time per week to assess and evaluate home safety needs, fall prevention, abuse prevention and medication management. P1 was prescribed a number of medications which included Buspar (an antianxiety), diazepam (for anxiety) as needed, Jardiance (for diabetes), Glucotrol (for diabetes), metformin (for diabetes), mirtazapine (an antidepressant), risperidone (an antipsychotic), semaglutide (for diabetes) injection, simvastatin (for cholesterol) and suvorexant (for sleep). Review of P1’s physician orders following clinic visit to establish care on 6/6/24, the following additional medications were listed as active medications on P1’s after visit summary: chlorpromazine (an antipsychotic medication) as needed (prn), clozapine (an antipsychotic medication), hydroxyzine (an antihistamine), metoprolol (to treat high blood pressure), olanzapine (an antipsychotic medication), Invega (an antipsychotic), MiraLAX (a laxative), quetiapine (an antipsychotic medication), quetiapine (an antipsychotic medication), risperidone (an antipsychotic medication) injection, and sildenafil (to treat erectile dysfunction) prn, Review of P1’s psychiatric office visit on 6/11/24, identified the following medication orders: risperidone, mirtazapine, diazepam prn, suvorexant prn, Buspar, simvastatin, semaglutide injection, glipizide and Jardiance. The visit note lacked evidence the provider prescribed Glucotrol, metformin and simvastatin for P1 as listed on his POC. P1’s electronic medical record (EMR) lacked evidence P1’s medications were reconciled in the home and any and all discrepancies were clarified with P1’s primary physician. When interviewed on 8/7/24 at 3:30 p.m., registered nurse (RN)-A stated she felt the practitioner who saw P1 on clinic visit 6/6/24, to establish care, had pulled an outdated medication list and so the after-visit summary medication list was not accurate. The psychologist who saw P1 on 6/11/24, had been P1’s primary and that medication list would be more accurate. The 6/11/24 medication list was also not the same as medications listed on P1’s POC. The agency expected staff to take all patient medication bottles in the home and do a medication reconciliation on each visit. If discrepancies were noted, the nurse would be expected to notify the patient’s primary physician and have the orders clarified. P3’s POC 7/22/24 to 9/19/24, identified a SOC 9/26/23. Diagnoses included heart and kidney disease with heart failure and end stage renal disease. Services included SNV one time every week for nine weeks to assess safety needs, pain, and long-term medication management. P3 was prescribed a number of medications which included albuterol inhaler (for spasm of lung air passages), allopurinol (to treat gout), apixaban (a blood thinner) atorvastatin (to treat cholesterol), B complex-C-folic acid vitamin, bumetanide (to reduce fluid), calcium acetate, phosphate binder (to treat high phosphate), diclofenac 1% external gel for join pain, vitamin D3, Lunesta (for sleep) Zetia (for cholesterol), finasteride (to treat enlarged prostate), Trelegy Ellipta inhaler (for lung disease), gabapentin (to treat neuropathic pain), guaifenesin-codeine syrup (for cough), hydrocortisone cream (for hemorrhoids), loratadine (for allergies), metolazone (to reduce fluid). metoprolol (to treat high blood pressure), montelukast (for allergies), ondansetron (to treat nausea), pantoprazole (a stomach acid reducer), polyethylene glycol (a laxative), senna-docusate (laxative) and trazodone (for sleep). Review of P3’s hospital discharge summary dated 6/28/24, identified his discharge medications which included the same medications listed on P3’s POC dated 7/22/24. The discharge medications also included lisinopril (for high blood pressure) daily, midodrine as needed during dialysis to treat low blood pressure, naphazoline-glycerin ophthalmic drops (to clear eyes) oxycodone as needed, and tamsulosin (for prostate) daily, none of which were listed on P3’s POC dated 7/22/24. P3’s EMR lacked evidence P3’s medications were reconciled in the home and any and all discrepancies were clarified with P3’s primary physician. During interview on 8/7/24, at 3:30 p.m. RN-A stated if P3 was no longer taking all the medications listed on the discharge summary the nurse should have notified the physician for clarification and corresponding orders to discontinue the medications should have been documented. RN-A did remember the dialysis unit had called and notified the agency to stop P3’s lisinopril as his blood pressure was running low but was unable to find documentation or order to stop the medication in P3’s EMR. It was the agency’s practice to write a physician order whenever a medication was initiated, changed or stopped. During telephone interview on 8/8/24, at 9:00 a.m. the home care director stated it was the agency’s practice to have the nurse write verbal orders for all medication changes, discontinuation of medications or initiation of medications. Nurses were expected to reconcile and clarify medications as needed at every visit. The agency policy Medication Reconciliation Process dated 5/14, identified the admitting nurse would complete a medication history, asking the client to provide a list of medications they are taking, prescription bottles and over the counter (OTC) medications against the physician orders, referral form and/or medication reconciliation form. The nurse would reconcile any discrepancies with the physician via telephone in person, by POC and/or interim order. The physician would reconcile the medications as noted by signing the interim orders and/or POC or giving a verbal order.”