Ste Genevieve Co Memorial Hosp 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 maintain an accurate/updated medication profile in one of three home visit observations conducted (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 policy titled, “Medication, Regimen Review Comprehensive,” reviewed 09/2024, showed in part: -At the time of admission an accurate, current and complete list of all prescription and over-the counter medications, as well as herbal medications, taken by the patient will be maintained on the medication profile; -The clinician will compare the medication list to those on the referral and any discrepancies will be reconciled with the physician and documented in the clinical record; and -Review/Update of medications will be done at each visit. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 02/12/2025 with a diagnosis of atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), and had additional diagnoses of hypertensive heart disease without heart failure (changes in the heart related to chronic elevation in blood pressure), contusion of left front wall of thorax (bruise to the rib) related to a recent fall, and type 2 diabetes mellitus (a group of diseases that results in too much sugar in the blood). He/she lived alone in an apartment. Review of the clinical record showed: -Review of the “Home Health (HH) Nursing Registered Nurse (RN) Admission Visit” note, dated 02/12/2025 (date of admission) showed in part, “(patient) does report he/she does have constipation issues that he/she takes a stool softener every other day and is effective.” This medication was not listed on the hospital discharge list or the provider’s medication list; -Review of the “HH Nursing RN Visit note, dated 02/20/2025, showed the patient had been prescribed a “z-pack” (antibiotic). The medication list dated 03/04/2025 at 8:57 AM failed to include this medication as a current or discontinued medication; and -The clinical record failed to contain documentation related to reporting/clarifying the medication discrepancies. Observation and interview on 03/04/2025 at 1:25 PM, during the patient’s home visit, showed the medications in the patient’s home did not match the provider’s medication list dated 03/04/2025 at 8:57 AM, or the hospital discharge medication list dated 02/11/2025. The patient stated the medications he/she used were on the kitchen table and some were in the bedroom in the bedside table. During the medication review, with the physical therapist (PT) present, the state agent (SA) noted several of the medications the patient was currently taking had the lid removed from the bottle. The following medication discrepancies were identified: -The hospital discharge medication list showed the patient was taking Melatonin (hormone used for a sleep aid) 3 milligrams (mg) daily at bedtime as needed for insomnia (inability to sleep). The provider’s medication list showed the patient was taking Melatonin 3 mg daily at bedtime as needed for insomnia. The patient had a bottle of Melatonin 5 mg that he/she stated they were taking daily as needed at bedtime; -The hospital discharge medication list showed the patient was taking acetaminophen (analgesic for pain or fever) 325 mg, take two tablets every six hours as needed for pain. The provider’s medication list showed the patient was taking acetaminophen 325 mg, take two tablets every six hours as needed for pain. The patient had a bottle of acetaminophen 500 mg tablets in the home that he/she was taking as needed; -The patient had a bottle of over-the-counter aspirin (treat mild to moderate pain) 81 mg that was with the group of medications he/she was using, and the lid was removed. The medication was not on the hospital discharge list or the provider’s medication list; and -The patient had a bottle of over-the-counter Nexium (decreases stomach acid) 20 mg beside his/her chair. When asked if that was being used, he/she stated “yes,” it is used for his/her “stomach when needed.” The medication was not on the hospital discharge list or the provider’s medication list. During an interview, 03/06/2025 at 1:15 PM, the administrator stated that the medications in the home should match the provider’s medication list. Discrepancies from the hospital discharge should be documented in the record, and medications would show up as discontinued on the medication list if they were added to the med list and an end date was entered.”

“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 provider failed to ensure the plan of care (POC) included all required treatments, in one of six records reviewed (Record/Patient #3). This deficient practice has the potential to affect the provision of care for all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” revised 12/30/2024, showed in part, the initial plan of care must include all treatments. RECORD/PATIENT # 3: Review of the clinical record showed the patient was admitted to home health on 02/14/2025 with a diagnosis of moderate protein-calorie malnutrition (nutritional disorder) and had additional diagnoses including influenza , unspecified bacterial pneumonia (lung infection), metabolic encephalopathy (a problem in the brain), and type 2 (two) diabetes mellitus (DM; a group of diseases that results in too much sugar in the blood). He/she lived at home with a spouse. Review of the “Home Health (HH) Nursing Registered Nurse (RN) Admission Visit”, dated 02/14/2025 (date of admission), included a “Prepare Patient Care: (Visit) Note” that showed: -A wound to the patient’s inner left buttock area that had a cream in place for treatment; and -The patient’s son managed the patient’s insulin (routine (set amount) and sliding scale (varies according to blood sugar readings)). Review of the POC dated 02/14/2025 to 04/14/2025, showed the POC failed to include: -Wound Care Orders-for the type of wound, location (left inner buttock area), cleaning instructions, or who was responsible for the treatment (the “cream” was listed on the medication list to “apply to affected area daily for wound treatment”; and -Orders related to who was responsible for managing the patient’s insulin/DM. During an interview on 03/06/2025 at 1:15 PM, the administrator stated orders should be listed on the plan of care.”

“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 ensure staff provided physician/allowed practitioner services as ordered on the plan of care (POC) in, two of six records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to impact the care provided to all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care,” revised 12/30/2024, showed in part, the plan of care will serve as physician’s orders for patient care, and all staff providing services will be in compliance with the orders. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health on 02/12/2025 with a diagnosis of atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular heartbeat), and had additional diagnoses of hypertensive heart disease without heart failure (changes in the heart related to chronic elevation in blood pressure), contusion of left front wall of thorax (bruise to rib area) related to a recent fall, and type 2 (two) diabetes mellitus (DM; a group of diseases that results in too much sugar in the blood) without complications. He/she lived alone in an apartment. Review of the POC, with certification dates 02/12/2025 to 04/12/2025, showed in part, the following: -Health Management Order(s): *”Physician notification Physician Notify” - * Blood Glucose > (greater than) 300 or in accordance with specific parameters that has been determined by the physician; and *”Physician Notification Physician notification” - *Weight gain: > 5 (five) lbs (pounds) in 1 week or 3 (three) pounds or more in 1 day; *Resting Heart Rate: >110 or (greater than) 300 or in accordance to specific parameters that has been determined by the physician; -“Physician Notification Physician notification” - *Weight gain: >5lbs in 1 week or 3lbs or more in 1 day; and -Failed to indicate who was responsible for diabetic management (patient is insulin dependent). Review of the clinical record showed: -“HH Nursing RN Admission Visit” dated 02/14/2025 that showed: *The RN documented in the “Prepare Patient Care: (Visit) Note” section; the patient’s son managed the insulin injections; *The note failed to include a blood sugar assessment (POC included order to notify physician of blood glucose over 300); and *The RN documented in the “Assess Weight and Measurements” section; an undated weight of 145 pounds (most recent measure in last 30 days). No new weight was documented for the date of admission to monitor the patient for weight gain per POC orders. -“HH Nursing RN Visit” dated 02/17/2025, failed to include an assessment/documentation of the patient’s weight; and -“HH Nursing RN Visit” 02/21/2025 failed to include an assessment/documentation of the patient’s weight or blood sugar. During an interview on 03/06/2025 at 1:15 PM, the administrator stated that staff should change the parameter orders to meet the needs of the patient and should remove any parameters that do not apply to the patient.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, record review, and interview, the provider failed to ensure the staff developed or sent a discharge summary in one of two discharge records reviewed (Record/Patient #6). This deficient practice has the potential to affect the ongoing provision of care for all the discharged patients. Findings included: Review of the provider’s policy titled, “Discharge / Transfer, Patient,” reviewed 09/2024, showed in part, the Discharge/Transfer Summary will be completed by the discharging discipline. The discharge summary will be sent within five business days of the patient’s discharge. RECORD/PATIENT #6: Review of the clinical record showed an order, written 11/26/2024, to discharge the patient from the provider’s services effective 10/24/2024. The clinical record failed to include a discharge summary. During an interview on 03/06/2025 at 1:15 PM, the home health administrator stated that there was no nursing discharge summary in the medical record.”