Good Shepherd Home Health 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 observation, interview and document review, the agency failed to ensure medication regimen review, and reconciliation of medications, was completed to ensure the medications on the plan of care (POC) were available, and were set up as ordered by the provider, for 1 of 3 (P3) patients observed during the home care visits. P3’s Home Health Certification and POC for certification period of 2/23/24 to 4/22/24, indicated P3’s primary diagnosis was hemiplegia (a loss of the ability to move one side of the body) and hemiparesis (one sided muscle weakness) following a cerebral infarction (stroke) affecting the left, non-dominant, side. P3’s POC also indicated other diagnoses which included thrombocytopenia (a condition where abnormally low level of platelets was observed. Platelets are involved with clotting of the blood.), hypertensive heart disease without heart failure (heart condition caused by high blood pressure), atherosclerotic heart disease (hardening of the arteries) of native coronary artery without angina pectoris (chest pain), urge incontinence, congenital hypothyroidism (underactive thyroid) insomnia, and cervicalgia (neck pain). P3’s POC indicated he received skilled nurse services weekly for assessment of skin breakdown, level of pain, and of GI (gastrointestinal-digestive system) status. The nurse was also to observe for signs and symptoms of urinary tract infections and educate P3 on this. The plan of care directed the nurse to monitor for change in neurological/mental status and assess and evaluate functional limitations. The POC lacked orders for medication set up for P3. On 4/10/24, at 8:30 a.m. registered nurse (RN)-A was observed during home visit with P3. Upon the initiation of visit, patient assessment was completed which included vital signs (temperature, pulse, respirations, and blood pressure with P3). RN-A also completed a review of systems, which included bowel function which included an assessment of bowel sounds, and RN-A inquired of frequency of bowel movements, appetite, and any nausea was experienced. RN-A then assessed the respiratory and cardiac status (inquired of chest pain, shortness of breath, cough, or of any swelling of the ankles. A pain assessment was completed and P3 reported his level of pain was at a 2.75 on a scale of 0-10 (zero being no pain and the level of ten being excruciating/unbearable). P3 stated his back pain had improved, however, he continued to have low back pain. P3 reported he received personal therapy twice weekly. RN-A was observed as she completed medication set up, using the medication profile printed prior to visit, and proceeded to set up medications. P3’s medications were set up in a removable tray, which was then inserted into a timed electronic medication dispenser. RN-A stated P3 also had a backup supply of one week in the home, which family would assist with in the event of an emergent or delayed visit at which time medication were unable to be set up. During the set-up of medications, the following discrepancies were noted: Calcium/Vitamin D tablet (600 mg/400 unit) one tablet daily for supplement was ordered and set up. A review of the prescription label indicated the medication was dispensed on 1/20/23, and was to be discarded after 1/19/24. Atorvastatin Calcium 20 mg was ordered at 10 mg (1/2 tablet) daily at bedtime was ordered and set up. A review of the prescription label indicated the prescription was dispensed on 1/6/23, and was to be discarded after 1/15/24. In addition to the above listed discrepancies, it was noted that although the following medications were listed under the section of the POC identified as Medications, RN-A failed to review availability of medications, and usage pattern, of the medications. Carbamide Peroxide Solution-Instill four drops to both ears every week for ear wax removal. The directions identified family manages, however, RN-A failed to inquire of effectiveness or ongoing use. Although bowel and digestive status were reviewed, the use of the following medications was not reviewed, and adequate supply was not assured. The following medications were ordered for bowel function: Sennosides Tab, 8.6 mg tablet was ordered as one to two tablets once daily as needed for constipation. P3 stated he had not used this medication and lacked a current supply. Bisacodyl Suppository, 10 mg one suppository as needed daily for constipation. P3 stated he had not used this and lacked a current supply. Polyethylene Glycol Powder, 17 grams with four to six ounces of liquid in the morning and at bedtime as needed for constipation. P3 stated he used this medication twice a day routinely and it was effective for bowel management. During the initial assessment, RN-A inquired of current pain status, as well as current therapy and exercise regime, however, failed to review the following medications: Lidocaine TDM, 5 % one patch daily as needed for pain. The directions directed P3 to leave on for up to 12 hours, and remove. The directions directed P3 to wait at least 12 hours before applying a new patch. P3 stated he has not used recently, and showed RN-A large supply of patches present. Bio Freeze gel 4%, as needed for pain. RN-A lacked review of usage pattern and availability of medication. Acetaminophen tablets, 325 mg tablets, two tablets every four hours as needed for pain. Following review of medications between RN-A and P3 clarification was requested by surveyor. P3 stated he used Tylenol 8HR Arthritis Pain, two tablets, twice a day, and reported this worked well. An open bottle of Tylenol 8HR Arthritis Pain medication was noted on the kitchen counter. The dosage of the medication was observed to be 650 mg, and the bottle contained 290 tablets. P3 reported he had used one bottle of this brand already and was partially into the second bottle. P3 stated he always keeps his Tylenol on the counter above the dishwasher. RN-A stated she had not noticed this brand of acetaminophen before. RN-A reviewed the dose of acetaminophen with P3, and explained to P3 he was currently taking 1300 mg twice daily. RN-A informed P3 the dose of medication ordered by provider was two tablets of 325 mg for a total of 650 mg every four as needed for pain. RN-A informed P3 she was going to follow up with the provider regarding both the current, and desired dose. Following the home visit, at 9:30 a.m. RN-A stated family members were responsible for ordering the medication for the patient. RN-A stated it was by the direction of the family the medication was to “used up” and not discarded. RN-A stated the recommendation was not to use after one year, or as identified on the “Discard After” date on the label, however, based on family direction, she had used the medication. RN-A stated meds were to be reviewed and reconciled with every medication set up, visit, and with recertification. On 4/10/24, at 1:32 p.m. the Director of Home Care Services stated medications should be reviewed with every visit, including medication set up. If a family member requested medications were to be used after the date they have expired or were to have been discarded, the family member should have been advised of the policy of the agency, and medications should not have been used for medication set up. A review of the facility policy, Drug Regimen Review, revised 8/2019, identified upon admission, a comprehensive assessment was to be completed at the time of admission and was to include Drug Regimen Review. The Drug Regimen Review was to include a review to identify any potential adverse effects and drug reactions, ineffective drug therapy, significant side effects or drug interactions, duplicate drug therapy, and noncompliance with drug therapy. In addition to the components listed, the nurse was to review with the patient the use of the medications to ensure their understanding which was to include storage and administration of medication, purpose of the medication and potential side effects, as well as effectiveness and appropriateness.”

“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 secure physician orders for 1 of 1 resident, (P3), who was observed for medication management. P3’s Home Health Certification and Plan of Care (POC) for certification period of 2/23/24 to 4/22/24, indicated P3’s primary diagnosis was hemiplegia (a loss of the ability to move one side of the body) and hemiparesis (one sided muscle weakness) following a cerebral infarction (stroke) affecting the left non-dominant side. P3’s POC also indicated other diagnoses which included thrombocytopenia (a condition where abnormally low level of platelets was observed. Platelets are involved with clotting of the blood.), hypertensive heart disease without heart failure (heart condition caused by high blood pressure), atherosclerotic heart disease (hardening of the arteries) of native coronary artery without angina pectoris (chest pain), urge incontinence, congenital hypothyroidism (underactive thyroid) insomnia, and cervicalgia (neck pain). P3’s POC indicated he received skilled nurse services weekly for assessment of skin breakdown, level of pain, and of GI (gastrointestinal-digestive system) status. The nurse was also to observe for signs and symptoms of urinary tract infections and educate P3 on this. The plan of care directed the nurse to monitor for change in neurological/mental status and assess and evaluate functional limitations. P3’s orders for skilled nursing services lacked indication of medication set up for patient. On 4/10/24, at 8:30 a.m. registered nurse (RN)-A was observed during home visit with P3. Upon the initiation of visit, patient assessment was completed which included vital signs (temperature, pulse, respirations, and blood pressure with P3). RN-A also completed a review of systems, which included bowel function which included an assessment of bowel sounds, and RN-A inquired of frequency of bowel movements, appetite, and any nausea was experienced. RN-A then assessed the respiratory and cardiac status (inquired of chest pain, shortness of breath, cough, or of any swelling of the ankles. A pain assessment was completed and P3 reported his level of pain was at a 2.75 on a scale of 0-10 (zero being no pain and the level of ten being excruciating/unbearable). P3 stated his back pain had improved, however, he continued to have low back pain. P3 reported he received personal therapy twice weekly. RN-A was then observed as she completed medication set up, using the medication profile printed prior to visit, and proceeded to set up medications, which were inserted into the timed electronic medication dispenser. During a follow up interview on 4/10/24, at 9:30 a.m., RN-A stated previously the medications had been set up and managed by the Assisted Living (AL) where the patient resided. RN-A stated P3 began with med set up by the agency approximately one to two months ago. RN-A stated they had been following P3 for skilled nursing visits, and family had requested that they begin med set up. RN-A stated she had not realized the order for medication set up had not been added to the orders for care. RN-A stated she was unsure of the exact date these services had been initiated. Upon review of skilled nursing visit notes, it was identified in the visit note of 1/17/24 “Family requesting that homecare take over the medication set up. Met with AL nurses this morning and meds are now in client’s apt [apartment].” During interview on 4/10/24, at 1:32 p.m., the Director of Home Care Services stated upon review of the narrative documentation, the services for medication set up was initiated on 1/17/24. The Director stated an order for medication set up was required before initiated. Upon review of the most recent POC, it was identified although initiated on 1/17/24, it was also not included with orders from the most recent recertification of 2/23/24 to 4/22/24. A review of the facility policy, Medication Set Up, revised 5/2016 identified the process of the medication set up, however, lacked indication orders must be received from a provider prior to initiating medication set up. The agency policy, Physician’s Orders, revised 12/2023, identified medications and treatments must be administered by a nurse or therapist qualified to perform the order. The policy outlined upon receipt, all applicable orders will be entered into appropriate computer system and/or placed on the client record.”