Clark County Home Health Agency

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure staff performed a complete medication review in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Policy for Use of Medication and Treatment Profile,” showed in part the following: - All drugs will be entered into the medication profile of the electronic health information; - The medication profile shall be updated whenever any changes in medications occur; - Medications and treatments will be reviewed by a skilled nurse at every home visit for any changes; - Nurses will update the medication profile as needed, and medications that are discontinued or added will be added to the profile upon completion of every visit; and - Patients/Caregivers/Responsible parties will have a medication profile in the home, and this will be reviewed and updated as needed with each skilled nursing and therapy visit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 4/13/2025 after an inpatient hospital stay for primary diagnosis of acute kidney failure (sudden decrease in kidney function that develops within seven days) and the patient resided at home with his/her spouse, and family and neighbors checked on him/her. The patient received skilled nursing and home health aide services. Observation on 4/29/2025 at 9:08 AM, showed the following: - The skilled nurse (SN) asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The state agent (SA) compared the provider’s medication profile to the patient’s medications and a medication list the patient had in their home. The following discrepancies were noted; * Humalog (fast-acting insulin) 100 unit/milliliters (ml) per sliding scale (S/S) subcutaneously (SQ- given under the skin) nightly: * The provider’s medication profile showed if the blood sugar (BS) was 150-199 = 2 (two) units. The medication list in the patient’s home showed 150-199 = 0 (zero) units; * The provider’s medication profile showed if BS was 200-249 = 4 (four) units. The medication list in the patient’s home showed 200-249 = 2 units. The patient stated that he/she was taking the insulin according to the sliding scale written on the medication list he/she had in their home; and * The provider’s medication profile showed melatonin (a hormone supplement used to aid sleep) disintegrating tablet 3 milligrams (mg) two by mouth daily at bedtime. The patient stated that he/she was taking one at bedtime and had been for approximately six months. During an interview on 04/30/2025 at 2:22 PM, the administrator stated that he/she expected the staff to reconcile the patient’s hospital list with what was in the patient’s home and any discrepancies were to be reported to the physician.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to provide physical therapy (PT) services at the frequency ordered in two of five full records reviewed (Records/Patients #1 and #4). This deficient practice has the potential to adversely affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Role Of The Skilled Nurse In The Agency,” revised 02/2016, showed in part the following: - The provider shall provide skilled nursing care to patients in the agency per written plan of care of the attending physician; - The registered professional nurse will coordinate services as the needs arises (i.e.: physical therapy, speech therapy, occupational therapy, home health aide); and - The registered professional nurse will keep the physician and other personnel informed of changes in the patient’s condition and needs. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services with a primary diagnosis of chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe). Review of the patient referral form dated 04/11/2025, showed the following: - Skilled nurse (SN): vital signs, general assessment, medication management and teaching; and - PT/Occupational therapy (OT): evaluate and treat. Review of the plan of care (POC) dated 04/14/2025 to 06/12/2025, showed PT to see the patient for an initial evaluation and to establish the POC. Review of the PT POC dated 04/15/2025 to 06/12/2025, showed PT visits were ordered two times a week for four weeks. Further review of the clinical record showed: - There failed to be two PT visits the week of 04/20/2025 to 04/26/2025; - There was a PT note documented in the electronic medical record (EMR) that showed the patient cancelled due to illness; and - There failed to be any communication by the SN with the physician regarding the PT failure to follow the visit frequency for the week of 04/20/2025 to 04/26/2025. (The record failed to show documentation that the PT tried to make up the missed visit during that week) RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 04/10/2025 with a primary diagnosis of multiple fractures (sternum, ribs, thoracic) from a motor vehicle accident. Review of the patient referral form dated 04/09/2025, showed the following: - Skilled nurse: vital signs, general assessment, medication management and teaching, disease process teaching; and - PT/OT: evaluate and treat. Review of the POC dated 04/10/2025 to 06/08/2025, showed PT to see the patient for initial evaluation and to establish the POC. Review of the PT POC dated 04/11/2025 to 06/08/2025, showed PT visits were ordered one time a week for one week, then two times a week for three weeks. Further review of the clinical record showed: - There failed to be two PT visits the week of 04/20/2025 to 04/26/2025; and - There failed to be any communication by the SN with the physician regarding the PT failure to follow the visit frequency the week of 04/20/2025 to 04/26/2025. (The record failed to show documentation that the PT tried to make up the missed visit during that week) During an interview on 04/30/2025 at 1:38 PM, the administrator stated that: - Staff were to make up the visit, if they could, that week; - If unable to make up the visit, staff were to notify the physician and write an order; and - There was no documentation the physician was notified of the missed visits.”