New Dimensions Home Health Care Inc.

“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 prepare medications only as ordered by a physician for 2 of 2 patients (P2, P3) reviewed for medication set up. Findings include: P2’s 485 (plan of care) for certification period 6/1/25 through 7/30/25 indicated P2 had diagnoses of anxiety, chronic pain syndrome, major depressive disorder, polyarthritis, post-traumatic stress disorder, and borderline personality disorder. P2’s physician signed 485 directed citalopram (Celexa, a medication to treat depression) 10 milligrams (mg) oral once a day and eszopiclone (Lunesta, a medication for insomnia) 1mg as needed at bedtime. P2’s psychiatric visit progress note, dated 5/23/25, indicated the following medication changes: citalopram 20 mg and eszopiclone 2 mg, as needed, at bedtime. During an observation on 6/5/25 at 2:30 p.m., registered nurse (RN)-B referenced the medication profile in P2’s electronic chart as she prepared the weekly set up of P2’s medication. RN-B set up citalopram 20 mg daily, when the chart instructed citalopram 10 mg daily. RN-B set up eszopiclone 2 mg daily at bedtime as needed, when the chart instructed 1 mg daily at bedtime as needed. Surveyor verified direction on medication profile with RN-B was for citalopram 10 mg daily and eszopiclone 1 mg at bedtime, as needed, with RN-B. RN-B did not attempt to contact the prescribing provider to clarify the medication dosage prior to completing the medication set up for P2. On 6/5/25 at 2:40 p.m., RN-B stated P2’s citalopram dose was increased to 20 mg and her eszopiclone was increased to 2 mg last week, but the computer (chart) was not updated. RN-B stated she was informed of the medication dose increase by the label on the prescription bottles. RN-B stated P2 had an appointment the week prior and she should have obtained the after visit note. RN-B stated, “it’s a transcription error on my part.” RN-B stated she had not made an attempt to clarify the medication dosage change with the provider. P3’s physician signed 485 for certification period 5/15/25 – 7/13/25 indicated P3 had diagnoses of chronic pain syndrome, fibromyalgia (a condition that involves widespread body pain and tiredness), rheumatoid arthritis, anxiety, and major depressive disorder. P3’s 485 directed Calcium 600 mg/Vitamin D 10mg oral daily and Cranberry 12,600mg oral daily. P3’s chart lacked a physician order for Calcium 600 mg/Vitamin D 20mg one tablet daily and Cranberry 15,000 mg one capsule daily. During an observation on 6/6/25 at 9:30 a.m., RN-C referenced the medication profile in P3’s electronic chart as she prepared the weekly set up of P3’s medication. RN-C set up Calcium 600 mg/Vitamin D 20mg daily, when the chart indicated Calcium 600mg/vitamin D 10mg. RN-C set up Cranberry 15,000mg daily, when the chart indicated Cranberry 12,600mg daily. Surveyor verified direction on medication profile with RN-C was for Calcium 600mg/vitamin D 10mg and Cranberry 12,600mg daily. RN-C did not attempt to contact the provider prior to completing the medication set up for P3. On 6/6/25 at 9:45 a.m., RN-C stated P3’s family picked up over-the-counter (OTC) medications. RN-C stated she would change the dosage in the computer (chart) and then send to the provider for approval. RN-C stated she would not call the provider for clarification of medication dosages. On 6/6/25 at 12:46 p.m., the director of nursing (DON) stated RN-B and RN-C should have had a conversation with the physician to clarify the prescription and OTC medication dosages, prior to setting the medication up for the patient. A facility document, Medication Set Up Policy (undated), directed the medication list is current and updated with physician/allowed non-physician practitioner orders as changes occur. A facility document, Medication Management (undated), directed RNs and LPNs assigned to client care providing medication management will verify prescription drugs are administered as prescribed. The policy also directed the agency will obtain a current written or electronically recorded doctor’s order, for all prescribed medication that the agency will be managing for the client.”