Vitalcaring Group

“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 provider failed to ensure a complete and accurate list of all the medications that the patient was currently using in, but not limited to, two of three home visit observations (Records/Patients #2 and #3). This deficient practice has the potential to affect the home health provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Review of the home health provider’s policy, titled “Medication List and Monitoring” latest revision dated 02/2023, showed in part the following: -To outline a process for ongoing medication monitoring; - The agency will maintain a current accurate list of all prescription, over the counter (OTC) and sample medications, herbals, and home remedies taken by the patient; - An agency Registered Nurse (RN) will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all agency staff involved in the patient’s / client’s care; - Medication monitoring will include appropriate data / information to develop an accurate patient / client medication history and a current complete medication profile. This data will be available to all agency staff involved in the patient’s / client’s care; - Professional clinical staff will update the medication list with any change in the medication regimen; and - Verification that medications listed have been reviewed to identify any potential adverse effects, and drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and non-compliance with drug therapy. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to the home health provider on 10/21/2023 for care of a pressure sore on the right great toe, and medication management. The patient lived at home. The patient received skilled nursing services. Observation on 12/18/2023 at 4:55 PM, during the patient’s home visit, showed the medications were reconciled by RN-B using a current medication profile supplied by the home health provider, and interview with the cognitive patient. This reconciliation showed the following discrepancies: - Furosemide (diuretic- a class of medicine that help reduce fluid buildup in the body) 80 milligram (mg) tablet, to be taken by mouth daily; and - Hydrochlorothiazide (diuretic- a class of medicine that help reduce fluid buildup in the body) 12.5 mg tablet, to be taken by mouth daily. The medications / empty bottle for the medications were not present and could not be located during the home visit medication reconciliation. During an interview on 12/18/2023 at 5:00 PM, RN - B stated his/her medication list showed the patient should be currently taking both Furosemide 80 milligram (mg) tablet by mouth daily, and Hydrochlorothiazide 12.5 mg by mouth daily. During an interview on 12/18/2023 at 5:05 PM, the cognitive patient did not provide an answer when asked if he/she took the two medications or the whereabouts of the containers for both medications. RECORD/PATIENT #3: Review of the clinical record showed the patient was admitted to the home health provider on 06/22/2023 after a hospital stay for coronary angioplasty (surgical procedure to open narrowed blood vessels to the heart), and chronic kidney disease with heart failure. The patient lived at home. The patient received skilled nursing services from the home health provider. Observation on 12/19/2023 at 9:10 AM, during the patient’s home visit, showed the medications were reconciled by RN-A using a current medication profile, supplied by the home health provider and interview with the patient. This reconciliation showed the following discrepancies: - Juice Plus Omega Capsule (a dietary supplement) - Four Tablets to be taken by mouth daily. The medication failed to be on the provider’s list; - Juice Plus Vegetable Blend Capsule (dietary supplement) - Three Tablets to be taken by mouth daily. The medication failed to be on the provider’s list; and - Juice Plus Berry Blend Capsule (dietary supplement) - Four Tablets to be taken by mouth daily. The medication failed to be on the provider’s list. During an interview on 12/19/ 2023 at 9:30 AM, the cognitive patient stated that he/she had taken the Juice Plus supplements for over a year. During an interview on 12/20/2023 at 4:00 PM, the administrator stated the following: - Staff are responsible for following the medication management policy, and asking the patient about medication changes each visit; - Staff are responsible to reconcile all medications including over the counter, and supplements with the patient; - Staff are to pull the medications bottles and compare to the medication list; and - Staff are to call the physician and get a correction with any discrepancies.”

“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 revies, record review, and interview, the provider failed to ensure the plan of care contained pertinent diagnoses and interventions to address the needs of the patient as identified in the initial comprehensive assessment in one of five records reviewed (Record/Patient #4). This deficient practice has the potential to affect the accurate care planning for all of the provider’s patients. Findings included: Review of the home health provider’s policy, titled “Plan of Care” latest revision dated 03/17/2023, showed, in part: - The agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client goals, actions or interventions that will resolve or alleviate the patient’s/client’s problems and/or needs; - All pertinent diagnoses; and - The plan of care must include all medications and treatments. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 11/22/2023 with a primary diagnosis of an open wound to the left lower leg. The patient resided in their own home with the assistance of family and friends. Review of the physical therapy start of care visit dated 11/22/2023, showed documentation that the family was cleansing a wound on the patient’s toe with betadine solution and covering the wound with a tape bandage two times per day. The documentation failed to show a wound on the patient’s left leg. The nursing evaluation dated 11/25/2023 failed to contain documentation of a wound on the patient’s left lower leg. Review of the plan of care dated 11/22/2023 to 01/20/2024 showed that: - The primary diagnosis for home health services was an open wound to the left lower leg; and - Contained orders for wound care supplies including wound cleanser, skin prep (pads), and bandages. The plan of care failed to: - Contain interventions for care of the wound on the left lower leg related to the primary diagnosis for care; and - Contain interventions for the wound on the patient’s right toe as identified in the comprehensive start of care assessment. During an interview on 12/19/2023 at 2:11 PM, the administrator stated that: - The plan of care dated 11/22/2023 failed to contain interventions for the care of the wound on the patient’s right toe; - The patient did not have a wound on the left lower extremity at the start of care evaluation visits; and - The primary diagnosis for the plan of care dated 11/22/2023 was incorrect.”