Visiting Nurse Association of Southeast Missouri, Inc.

“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 maintained an accurate/updated medication profile in three of three home visit observations conducted (Records/Patients #1, #2, and #3). This deficient practice has the potential to affect all the patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/17/2025 with a primary diagnosis of cervical radiculopathy (injury or damage to nerve roots in the area where they leave the spine at the neck). The patient resided in his/her own home with the assistance of his/her adult children daily. Review of the provider’s current medication profile showed in part: - Gabapentin (a medication used to treat nerve pain) one capsule daily; and - Losartan (a medication used to lower blood pressure) one tablet by mouth daily. Observation and interview on 08/05/2025 at 9:15 AM showed the following medication regimen discrepancies: - He/she had not taken the gabapentin since he/she was discharged from the hospital on 07/13/2025; and - He/she had stopped taking the losartan on 07/17/2025 at the request of his/her adult children because of low blood pressure. During an interview on 08/06/2025 at 10:25 AM, the administrator stated they would expect their clinicians to perform medication reconciliation each visit. Findings included: Review of the provider’s policy titled, “Medication Reconciliation” dated 2020, showed in part: PURPOSE: - The purpose of Medication Reconciliation is to compare a patient’s medication orders to all the medications that the patient has been taking, including any herbs or over the counter (OTC) medications; - This reconciliation is done to avoid medication errors such as omissions, duplication, dosing errors, or drug interactions; and - A medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medication list and comparing this list to those in the patient’s medical records. Steps of Medication Reconciliation: - Collect an accurate medication history by asking the patient to gather all the medications they may take including supplements and OTC medications. Home health includes all medications they may have taken in the last 30 days; - Clarify the medication names, strengths, routes, and frequency with the patient/legal representative; - Reconcile the medications in the home with the physician or hospital/facility if current medication orders were received with referral. The hospice nurses will consult the hospice physician/attending physician regarding new medications needed, discontinuation of any current medications, and to determine what meds are related or not related to the hospice care that is ordered upon admission to hospice and as needed thereafter; - Home health nurses must contact the physician or hospital/facility and have them send an official list of medications for the patient to complete a medication reconciliation if the referral did not originally send one; and - If there is a discrepancy, contact the physician for order clarification. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 02/28/2025 with a primary diagnosis of an above the knee amputation of the left leg, and secondary diagnoses which included Peripheral Vascular Disease (PVD; condition where blood vessels outside of the heart and brain narrow, affecting blood flow to limbs), hypertension, (abnormally high blood pressure), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided at home with a spouse. Observation and interview on 08/05/2025 at 10:45 AM, during the patient’s home visit, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for melatonin (an OTC hormone that helps regulate sleep-wake cycles) 3 milligrams (mg) tablet, take one tablet by mouth, daily at hour of sleep (HS) The patient stated that he/she had not used the medication; -The medication profile showed an order for methocarbamol (a medication to relieve pain and muscle spasms ) 500 mg tablet, one tablet to be taken by mouth, every eight hours as needed. The patient stated that he/she no longer used the medication; -The patient took trazadone (an antidepressant) 50 mg tablet, take one tablet, by mouth, daily at HS. This medication was not included on the provider’s medication profile; and -The patient took vitamin D3 (a vitamin supplement),1.25 mg tablet, take one tablet, by mouth, each month. This medication was not included on the provider’s medication profile. During an interview on 08/05/2025 at 11:30 AM, physical therapist (PT) - A stated he/she does not normally visit the patient, however, each patient should have their medication checked and compared to the current medication list during each visit to ensure accuracy. PT- A stated that he/she would notify the patient’s nurse regarding the discrepancies. During an interview on 08/06/2025 at 10:25 AM, the administrator stated that all staff should follow the policy, which consists of the visual comparison of all current medications in the patient’s home to the medication list during each visit to ensure accuracy. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” dated 2020, showed in part: - Purpose: * The purpose of Medication Reconciliation is to compare a patient’s medication orders to all the medications that the patient has been taking, including any herbs or over the counter (OTC) medications; * This reconciliation is done to avoid medication errors such as omissions, duplication, dosing errors, or drug interactions; and * A medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medication list and comparing this list to those in the patient’s medical records. - Steps of Medication Reconciliation: * Collect an accurate medication history by asking the patient to gather all the medications they may take including supplements and OTC medications. Home health includes all medications they may have taken in the last 30 days; * Clarify the medication names, strengths, routes, and frequency with the patient/legal representative; * Reconcile the medications in the home with the physician or hospital/facility if current medication orders were received with referral. The hospice nurses will consult the hospice physician/attending physician regarding new medications needed, discontinuation of any current medications, and to determine what meds are related or not related to the hospice care that is ordered upon admission to hospice and as needed thereafter; * Home health nurses must contact the physician or hospital/facility and have them send an official list of medications for the patient to complete a medication reconciliation if the referral did not originally send one; and * If there is a discrepancy, contact the physician for order clarification. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 02/28/2025 with a primary diagnosis of an above the knee amputation of the left leg, and secondary diagnoses which included peripheral vascular disease (PVD; condition where blood vessels outside of the heart and brain narrow, affecting blood flow to limbs), hypertension, (abnormally high blood pressure), and diabetes (a group of diseases that results in too much sugar in the blood). The patient resided at home with a spouse. Observation and interview on 08/05/2025 at 10:45 AM, during the patient’s home visit, showed the following medication discrepancies with the provider’s medication profile: -The medication profile showed an order for melatonin (an OTC hormone that helps regulate sleep-wake cycles) 3 milligrams (mg) tablet, take one tablet by mouth, daily at hour of sleep (HS) The patient stated that he/she had not used the medication; -The medication profile showed an order for methocarbamol (a medication to relieve pain and muscle spasms ) 500 mg tablet, one tablet to be taken by mouth, every eight hours as needed. The patient stated that he/she no longer used the medication; -The patient took trazadone (an antidepressant) 50 mg tablet, take one tablet, by mouth, daily at HS. This medication was not included on the provider’s medication profile; and -The patient took vitamin D3 (a vitamin supplement),1.25 mg tablet, take one tablet, by mouth, each month. This medication was not included on the provider’s medication profile. During an interview on 08/05/2025 at 11:30 AM, physical therapist (PT) - A stated he/she does not normally visit the patient, however, each patient should have their medication checked and compared to the current medication list during each visit to ensure accuracy. PT- A stated that he/she would notify the patient’s nurse regarding the discrepancies. During an interview on 08/06/2025 at 10:25 AM, the administrator stated that all staff should follow the policy, which consists of the visual comparison of all current medications in the patient’s home to the medication list during each visit to ensure accuracy. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 02/28/2025 with a primary diagnosis of encounter for adjustment and management of VAD (vascular access device - a medical device used to gain long-term access to a patient’s bloodstream for administering medications, fluids or for blood draws). The patient had additional diagnoses of osteomyelitis of cervical vertebrae (infection of the bone of the spine) and current long-term use of antibiotics. The patient lived in his/her own home and had a sibling who assisted with care as needed. Observation and interview on 08/05/2025 at 9:30 AM, showed: -The provider’s medication list had acetaminophen (used for mild pain/fever) 325 milligrams (mg) two tablets per g-tube (enteral feeding tube; a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication), every six hours. The patient stated that he/she had not used it for quite a while; -The provider’s medication list had amlodipine (for blood pressure) 10 mg per g-tube, daily. The patient stated that he/she took the medication by mouth and had not taken it per g-tube for a while; -The provider’s medication list had losartan (for blood pressure) 100 mg per g-tube, daily. The patient stated that he/she took the medication by mouth and had not taken it per g-tube for a while; -The provider’s medication list had Osmolite 1.5 Cal (refers to calories per milliliter (mL)) liquid (nutritional supplement) per g-tube four times a day. The patient stated that he/she had been drinking it by mouth; -The provider’s medication list had oxycodone (narcotic pain medication) 5 mg/5 mL, per g-tube every four hours, as needed (PRN) for pain. The patient stated that he/she had not taken it since he/she was discharged from the hospital (on 02/02/2025); -The provider’s medication list had senna plus (for constipation) 8.6mg-50mg, one tablet twice daily per g-tube. The patient stated that he/she had not taken the medication since he/she was discharged from the hospital; - The provider’s medication list had chlorhexidine gluconate 0.12% mouthwash (used to reduce bacteria in the mouth), 15mL four times daily. The bottle in the patient’s home, last filled on 07/16/2025, showed the patient was to use the mouthwash twice a day; - The patient had an antibiotic, amoxicillin 400mg – potassium clavulanate 57mg/5 mL, two times a day for 10 days per g-tube. The provider’s medication list failed to include the duration for the antibiotic; and - The patient had a bottle of hydrocodone (narcotic pain medication)/ acetaminophen 10 mg/325 mg, take one by mouth three times a day PRN. The label was dated/filled 07/08/2025 and the provider’s medication list failed to include the hydrocodone. During an interview on 08/06/2025 at 10:23 AM, the administrator stated that staff should have reconciled the patient’s medication at every visit and updated the profile with any changes. He/She would expect staff to notify the patient’s physician if the patient was no longer taking a medication. He/She would have expected all clinicians to have caught the medication discrepancies. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/17/2025 with a primary diagnosis of cervical radiculopathy (injury or damage to nerve roots in the area where they leave the spine at the neck). The patient resided in his/her own home with the assistance of his/her adult children daily. Review of the provider’s current medication profile showed in part: - Gabapentin (a medication used to treat nerve pain) one capsule daily; and - Losartan (a medication used to lower blood pressure) one tablet by mouth daily. Observation and interview on 08/05/2025 at 9:15 AM showed the following medication regimen discrepancies: - He/she had not taken the gabapentin since he/she was discharged from the hospital on 07/13/2025; and - He/she had stopped taking the losartan on 07/17/2025 at the request of his/her adult children because of low blood pressure. During an interview on 08/06/2025 at 10:25 AM, the administrator stated they would expect their clinicians to perform medication reconciliation each visit.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure that the patient’s individualized plan of care (POC) included the types of services, supplies, and equipment needed for patient care in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect all of the patients served by the provider. Findings included: Review of the provider’s policy titled, “Care Planning & Coordination,” dated 03/2022, showed the individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 07/20/2025 with a primary diagnosis of dysphagia (difficulty swallowing foods or liquids). The patient had a suprapubic urinary catheter (a catheter surgically inserted through the wall of the abdomen into the bladder) and and a gastrostomy tube (enteral feeding tube; a tube placed surgically through the abdominal wall into the stomach for the administration of food, fluids, and medication) He/she lived at home with a primary caregiver. Review of the POC, dated 07/20/2025 to 09/17/2025, showed “skilled nurse (SN) to instruct patient/caregiver in indwelling urinary catheter management including care of the suprapubic catheter” and “skilled nurse for teaching and administration of gastrostomy feedings to include care of equipment and preparation of feedings”. The POC failed to contain specific interventions and education for the care and maintenance for the suprapubic catheter and gastrostomy, including all gastrostomy equipment. During an interview on 08/06/2025 at 9:30 AM, the home health administrator stated that he/she could not locate specifics regarding catheter or gastrostomy tube care on the POC.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure clinicians promptly notified the patient’s physician/allowed practitioner of any changes in the patient’s condition or needs that suggested that outcomes were not being achieved and/or that the plan of care should be altered in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all the patients served by the provider. Findings included: RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to home health services on 07/17/2025 with a primary diagnosis of cervical radiculopathy (injury or damage to nerve roots in the area where they leave the spine at the neck). The patient resided in his/her own home with the assistance of his/her adult children daily. Review of the provider’s current medication profile showed in part: - Gabapentin (a medication used to treat nerve pain) one capsule daily; and - Losartan (a medication used to lower blood pressure) one tablet by mouth daily. Observation and interview on 08/05/2025 at 9:15 AM, showed that the patient had not taken gabapentin, and stated that he/she had not taken the gabapentin since he/she was discharged from the hospital on 07/13/2025, and losartan since 07/17/2025 related to low blood pressure. Review of the nursing visit note dated 08/5/2025 showed in part that: - The patient reported he/she was not taking gabapentin and losartan; - The nurse discontinued the medications and marked them off the patient’s medication list that was left in the home; - The visit note failed to contain documentation that the skilled nurse notified the physician that the patient was not taking gabapentin and losartan. During an interview on 08/06/2025 at 10:25 AM, the administrator stated that they would expect clinicians to notify the physician of when a patient was not taking his/her medications as prescribed, and they were unable to locate documentation that the physician had been notified that the patient was not taking gabapentin and losartan. Review of the provider’s policy titled, “Licensed Practical Nurse Job Description,” dated 07/2021, showed, in part, the following job duties/responsibilities: -Makes pertinent nursing observations and communicates these to the R.N. (registered nurse) Staff Nurse or the physician and/or case worker when appropriate and document in a timely manner; -Inform doctor of changes in patient’s conditions, with documentation of changes in narrative notes; and -Follow the plan of care as initiated by the R.N./physician. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 02/28/2025 with a primary diagnosis of encounter for adjustment and management of VAD (vascular access device - a medical device used to gain long-term access to a patient’s bloodstream for administering medications, fluids or for blood draws). The patient had additional diagnoses of osteomyelitis of cervical vertebrae (infection of the bone of the spine) and current long-term use of antibiotics. The patient lived in his/her own home and had a sibling who assisted with care as needed. Review of the recertification plan of care (POC), dated 06/28/2025 to 08/26/2025, showed in part: -Skilled nurse (SN) was to obtain CBC with differential (complete blood count – a blood test that provides information about the different types of cells in your blood, including red blood cells, white blood cells and platelets) and CMP (complete metabolic panel – a blood test that measures 14 different substances in your blood, providing a broad overview of your body’s metabolism and chemical balance) weekly; and -SN was to perform IV (intravenous, in the vein) flush of each lumen (port) of power PICC (Peripherally Inserted Central Catheter - a catheter inserted into a peripheral vein and ending in a large vessel above the heart) line as follows: after discontinuing infusion, after each use or every 24 hours – flush central line with ten cc (cubic centimeters) of normal saline (NS) followed by three to five cc heparin (to keep blood from clotting). When drawing blood, flush with ten cc NS, withdraw three to five cc of blood using a five cc syringe and discard, draw blood for lab using a five cc syringe, flush with 20cc NS using a pulsating method, follow with three to five cc heparin. Review of the SN visit note, dated 07/01/2025, showed in part, the patient had a double lumen PICC line to the left upper arm. The nurse attempted to draw labs from PICC line with no blood return noted. The lines flushed without difficulties. The SN drew blood from right antecubital (AC, area to inner elbow) without difficulties. The POC and physician orders failed to include an order for venipuncture (the process of puncturing a vein with a needle to draw blood) to obtain blood draws. During interview on 08/06/2025 at 10:23 AM, the administrator stated that he/she would expect the staff to contact the patient’s physician to obtain an order for venipuncture for blood work if they were unable to draw blood from the patient’s PICC line.”

“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, home visit observation, and interview, the provider failed to ensure the clinicians provided services that are ordered by the physician or allowed practitioner as indicated in the plan of care in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect the provision of care for all the provider’s patients. Findings included: Review of the provider’s policy titled, “Job Description Registered Nurse (RN),” dated 10/2021 showed, in part, the RN makes initial evaluation visits as assigned, assesses patient needs, and provides skilled nursing care and prescribed treatments as ordered by the physician. Review of the provider’s policy titled, “Job Description LPN (Licensed Practical Nurse),” dated 07/2021, showed, in part, the duties of the LPN included: -Makes pertinent nursing observations and communicates these to the R.N. / Staff Nurse or the physician and/or case worker when appropriate and document in a timely manner; -Inform doctor of changes in patient’s conditions, with documentation of changes in narrative notes; and -Follow the plan of care as initiated by the R.N./physician. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 02/28/2025 with a primary diagnosis of encounter for adjustment and management of VAD (vascular access device - a medical device used to gain long-term access to a patient’s bloodstream for administering medications, fluids or for blood draws). The patient had additional diagnoses of osteomyelitis of cervical vertebrae (infection of the bone of the spine) and current long-term use of antibiotics. The patient lived in his/her own home and had a sibling who assisted with care as needed. Review of the plan of care (POC) dated 06/28/2025 to 08/26/2025, showed the patient had a power PICC (Peripherally Inserted Central Catheter – a catheter inserted into a peripheral vein and ending in a large vessel above the heart) in the left arm. Staff were to measure arm circumference weekly for edema (swelling of tissues): “From insertion site, measure up to the mid bicep area. Measure around the arm to see if there is a change. If increase in cm (centimeters) circumference, notify physician”. Review of the LPN visit notes completed on 07/01/2025, 07/08/2025, 07/15/2025, 07/22/2025, and 07/29/2025, failed to contain documentation that the nurse measured the circumference of the patient’s left upper arm. Observation on 08/05/2025 at 9:30 AM, showed the RN performed the following interventions to the patient’s left arm PICC site: - Sterile dressing change; - Changed the extension tubing and caps; - Drew blood for labs; - Flushed ports; and - The RN failed to obtain measurements of the left upper arm as ordered in the POC. Per an interview conducted immediately following the home visit, RN-D stated that he/she did not measure the arm circumference, but it was still an active order. The dressing change kit usually came with a measuring tape. He/she did not see one in the kit, and he/she did not remember to measure the upper arm. During an interview on 08/05/2025 at approximately 11:00 AM, the administrator stated that RN-D had called the office after the home visit and he/she sent RN-D back into the patient’s home to obtain the upper arm measurement because it should have been measured. During an interview on 08/06/2025 at 10:34 AM, the administrator stated that he/she would expect the staff to follow the plan of care and measure the arm circumference of the patient during each visit.”