Lewis 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, clinical record review, home visit observation, and interview, the home health provider failed to ensure a complete and accurate medication list was maintained in, two of three home visit observations (Records/Patients #1 and #4). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patient’s served by the provider. Findings included: Review of the provider’s policy, dated effective 04/30/2024, titled, “Drug Regimen Review,” showed in part: - The “Named Home Health Provider” must prepare, and provide to the patient and his or her caregiver (if any) written information regarding the patient’s medication regimen as based on the results of the medication review conducted; - A current medication profile will be kept in the patients initial visit packet in the home; - In the event there is a concern identified with the patient’s medication it should be reported to the physician signing home health orders; - The patient’s clinical record should identify all medications that the patient is taking both prescription and non-prescription including dosage, instructions, and route; - As medication changes occur the nurse should consider, and the clinical record should document, that the nurse considered each medication the patient is currently taking for possible side effects and the list of medications in its entirety for possible drug interactions; - medication changes reported to a therapist or home health aide by a patient and or caregiver need to be communicated to the nurse. The nurse will then contact the physician for new orders regarding changes to current medication profile. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 08/23/2024 with a principal diagnosis of Saddle Embolus of the pulmonary artery (a rare and life-threatening condition that occurs when a large blood clot blocks the main pulmonary artery from branching off into the lungs). Review of the current medication profile supplied by the provider, and printed on 09/03/2024 showed, in part: - Ropinirole HCL 1mg (milligram) tablet, take 2 tablets by mouth once a day at bedtime (for restless leg syndrome); - It failed to list Mounjaro 7.5mg (an injectable medicine used to improve blood sugar) or Duloxetine 60mg (used to treat depression). Observation on 09/04/2024, starting at 10:06AM, during the patient’s medication reconciliation (while RN (registered nurse) A was observing the patient’s spouse fill the weekly medication panner), the following discrepancies were noted when comparing what the patient was taking with the current medication profile supplied by the provider: - Mounjaro 7.5mg failed to be listed on the current medication profile; - Duloxetine 60mg failed to be listed on the current medication profile; and - Ropinirole HCL 1mg was listed on the profile. but the spouse was unable to locate this medication. Per interview conducted during the observation the patient and spouse stated that he/she (the patient): - Was taking Mounjaro 7.5mg weekly on Sunday and had been taking for maybe two or three months; - Was taking Duloxetine 60mg 1 capsule twice a day (fill date on bottle was 06/28/2024; and - Was unable find any Ropinirole HCL 1mg and was unsure if it was being taken or not. Per interview conducted during the observation, RN A stated that he/she: - Knew the patient had been taking the Ropinirole HCL 1mg because he/she had numbered the medications, and it was listed as number 8; - Did not recall the patient mentioning taking the Mounjaro; and - He/she would get all the discrepancies clarified. During an interview on 09/04/2024 starting at 1:45 PM the RN/home health supervisor stated that he/she: - Would expect all medications the patient is taking to be on the medication profile and how many they are taking; and - We may need to call the Doctor and ask if the order can read one or two. RECORD/PATIENT #1: Review of the clinical record showed the patient was admitted to home health services on 08/16/2024 with a primary diagnosis of (subsequent encounter for a closed fracture of the lower end of the left radius with routine healing, specified disorders of bone density and structure of left thigh, generalized osteoarthritis (chronic condition that causes the cartilage in joints to break down over time, resulting in pain, stiffness, and swelling), low back pain, chronic pain and hypercalcemia (too much calcium in your blood). - Observation on 1/31/2024 at 11:10 AM, during the patient’s home visit, showed the following: - The skilled nurse asked the patient if there had been any medication changes. The patient verbalized there had been no changes; - The state surveyor reviewed the provider’s Medication Profile form (printed on 09/03/2024) with the skilled nurse, along with the patient present, with the following discrepancies; * Acetaminophen 500 milligrams (mg) two tablets three times a day as needed for pain. The patient stated he/she had been taking one tablet in AM and PM for over a year; * Calcitriol 0.25 mg capsule take one capsule daily. The patient stated he/she had been taking one every other day for a month; * Nortriptyline HCI 25 mg take one capsule daily at bedtime as needed for sleeplessness. The patient stated he/she takes two at bedtime; * Prednisone 5 mg take a half a tablet once a day. The bottle showed 2.5 mg take a half (1.25 mg) tablet daily and the patient stated he/she takes 2.5 mg a half (1.25 mg) tablet daily; and * Tramadol 50 mg take two tablets every eight hours as needed for pain. The bottle showed 50 mg one every six hours as needed and the patient stated he/she takes two in the AM and PM.”

“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 policy review, record review, and interview, the home health provider failed to follow the plan of care (POC) when they discharged a patient without a physician order in one of two discharge records reviewed (Record/Patient #5). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “18 Home Health Discharge, Transfer and Referral Policy,” dated reviewed 11/10/2021, showed in part: - Discharge or transfer from this agency (provider) may occur if your physician who is responsible for your home health plan of care and our agency agree that the measurable outcomes and goals of your plan of care have been achieved and you no longer need home health services; and - Any revisions related to plans for discharge will be communicated with client, their representative, their caregiver, all physicians issuing orders for the client’s agency plan of care, client’s primary care practitioner and any other healthcare professionals who will be providing care and services to the client after discharge from our agency RECORD/PATIENT #5: Review of the clinical record showed the patient was admitted to the provider on 02/26/2024 with aftercare following kidney transplant (a surgical procedure that replaces a diseased or damaged kidney with a healthy kidney from a donor), hypertension (high blood pressure), and nonrheumatic mitral valve disorder (a group of heart conditions that affect the mitral valve, which is one of the heart’s valves). Review of the POC dated 02/26/2024 to 04/25/2024 showed: - SN (skilled nursing) 2wk9 (two times a week for nine weeks) (18 total visits); and - Lab specimen (blood) draws on Mondays and Thursdays, and urine specimen on Monday’s. Review of the clinical record showed two SN visits made during week one and two, and one SN visit during week three and week four. The SN discharged the patient on 03/18/2024 at the sixth visit. Further review of the clinical record failed to show a physician’s orders had been obtained for the SN to discharge the patient. During an interview on 09/05/2024 at 2:20 PM, the registered nurse/home health supervisor stated that he/she thought the discharge summary was sufficient for a discharge order. The patient wanted to do his/her labs outpatient and no more home health.”