Aw Health Care

“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 provider failed to ensure a complete and accurate review of all medications were completed in one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect the provider’s ability to ensure safe and effective use of medications for all patients served by the provider. Findings included: Review of the provider’s policy,” Medication, Regimen Review Comprehensive, “last revised 03/2023, showed in part the following: - The Registered Nurse (RN) will be responsible for monitoring the patient’s medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient’s care; - All required comprehensive assessments will include a review of all medications the patient is currently using 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; - At the time of admission an accurate, current, and complete list of all prescription and over-the­ counter (OTC) medications, as well as herbal medications, taken by the patient will be maintained on the medication profile; - Every effort will be made to reconcile any discrepancies with the physician or designee the next calendar day of the assessment; - The clinician will document this contact and any difficulties experienced in obtaining physician response. The clinician will notify the Director of Home Health Clinical Manager if there is no response from the physician on medication reconciliation. If provider staff other than the clinician responsible for completing the patient’s Start of Care (SOC) or Resumption of Care (ROC) Outcome and Assessment Information Set (OASIS) contacted the physician to follow up on clinically significant medication issues, this information must be communicated to the clinician responsible for the SOC/ROC OASIS assessment, so that the OASIS appropriate response may be selected. This collaboration does not violate the requirement that the comprehensive patient assessment is the responsibility of and must ultimately be completed by one clinician; - The medication profile will be placed in a highly visible place and include essential information about dosages, drug schedules, immunizations, and drug allergies. This medication profile will also include the medication action/classification, dosage administration schedule, route, initial order, and discontinuation dates, where applicable and if drug is new (N) or changed (C); - Nursing staff will assess on an ongoing basis the patient’s response to the medication and the patient/caregiver’s compliance with the medication regimen to include the appropriateness of the medication, adverse patient response, lack of patient response, and/or compliance concerns will be communicated to the physician as well as documented in the clinical record; - Changes in the medication regimen will be documented in the clinical record as well as communicated to the patient and/or caregiver; and - The review of medications will be on-going but done a minimum of every 60 days. The clinician will communicate a complete list of the patient’s medications to the next service provider when the patient is referred or transferred to another setting service, practitioner, or level of care within or outside the organization. The communication is documented in the clinical record. An updated version of the medication list will be provided in a timely manner to the patient following any changes, and prior to discharge from the provider. RECORD/PATIENT #2: Review of the clinical record showed the patient was re-admitted to home health services on 12/22/2024, following a hospitalization to treat acute respiratory failure, pneumonia (infection of the lung ), and also had diagnoses which included chronic obstructive pulmonary disease (COPD; a group of lung diseases that block airflow and make it difficult to breathe), diabetes ( a chronic, metabolic disease characterized by elevated levels of blood sugar and depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest. Review of the most current medication list provided by the provider, showed an active order for Desipramine (antidepressant and nerve medication) 25 milligram (mg) two tablets to be taken nightly for mood. Observation and interview on 02/06/2024 at 3:30 PM, during the patient’s home visit, showed the following medication discrepancy: Desipramine 25 mg two tablets to be taken nightly for mood. The patient stated that he/she had taken prior to going to the hospital, but hadn’t taken any since returning home on 12/22/2024 following a discussion with his/her physician. During an interview conducted on 02/06/2024 at 3:40 PM, RN-A stated the following: - The patient’s current medication profile showed Desipramine 25 mg tablets, 2 tablets to be taken nightly for mood and the order status marked as active; and - He/she would get all the discrepancies clarified. During an interview on 02/06/2024 starting at 3:30 PM the Clinical Manager the following: - The staff are responsible to ensure each patient’s medication reconciliation is accurate when comparing the provider’s medication list to the medication (s) the patient is currently taking in the home; and - The staff are responsible for clarifying and resolving all medication discrepancies with the patient’s physician, to ensure accuracy of medication on the profile list are those medications taken by the patient.”