Bayada Home Health Care Inc.

“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 agency policy, clinical record review, home visit observations, and staff interviews, the medication profile failed to include all/current medications the patient was taking for 4 of 5 home visits (#6, 7, 9, and 12). The findings included: The policy, Medication Management and Administration (1/1/1993), was presented by the agency director on 3/26/25 at 11:53 am. The policy stated, “…medication reconciliation should be done on every assessment and reassessment…” The policy, Client Care Plan (1/1/1993), was presented by the agency director on 3/26/25 at 11:53 am. The policy stated, “…the individualized plan of care…must include the following elements…all medications and treatments…” 1. Patient #6 had a Start of Care date of 8/14/2024 with an admitting diagnosis of cutaneous abscess of right foot. (a localized collection of pus that forms under the skin caused by a bacterial infection). Review of the POC for the certification period 2/10/25-4/10/25 included orders for SN (skilled nurse) 3 times a week for 8 weeks, 2 times a week for 1 week. On 3/24/25 at approximately 1:10 pm, a joint visit was conducted with RN#2. During the visit a medication review was conducted using the medication profile on the plan of care, provided by the agency. The following discrepancies were noted: The patient’s home medications included a men’s multivitamin taken daily, Melatonin (an artificial hormone supplement that helps with falling asleep) 5mg as needed at bedtime, and Glucose tablets (used to raise low blood sugar) as needed. The patient stated they take these medications when needed. These medications were not found on the medication profile. During an interview with the agency director on 3/26/25 at approximately 11:00 am, the director confirmed that the medication profile did not include the correct medications. 2. Patient #7 had a Start of Care date of 3/6/2025 with an admitting diagnosis of Chronic respiratory failure with hypoxia (lungs do not function effectively causing low oxygen levels in the blood). Hospice contracted the home health agency for physical therapy (PT) services. Review of the Plan of Care (POC) for the certification period 3/6/265 -5/4/25 included orders for PT 1 time a week for 7 weeks. On 3/24/25 at approximately 2:45 pm, a joint visit was conducted with PT #1. During the visit a medication review was conducted using the medication profile on the POC, provided by the agency. The following discrepancies were noted: A. The medication profile listed Cephalexin (antibiotic) 500mg daily. The medication bottle found in the home listed Cephalexin 250mg every other day. The patient verified that this is the correct dose. B. The medication profile listed Hydrocodone 10mg-chlorpheniramine (a narcotic cough medicine containing an opioid) 8mg/5ml every 12 hours as needed for cough. The medication bottle found in the home was for Hydrocodone 5mg-homatropine (a narcotic cough medicine containing an opioid) 1.5mg/5ml every 6 hours as needed for cough. The patient verified that the one in the home is the correct medication. C. The medication profile listed Advair diskus (an inhaler used to treat wheezing) 250mcg daily. The patient stated they use this inhaler twice a day. D. The medication profile listed oxygen at 3 liters per minute. The home oxygen concentrator was set at 2.5 liters per minute. The patient verified that 2.5 liters per minute is the correct setting. In addition, the following medications were not listed on the medication profile but were found in the patient’s home in their hospice-provided symptom control kit: E. Morphine (narcotic medication used to treat pain or shortness of breath) 20mg per 1ml every 3 hours as needed for shortness of breath. F. Prochlorperazine (used to treat nausea) 10mg every 6 hours as needed for nausea. G. Acetaminophen (used to treat pain or fever) 50mg every 6 hours as needed for pain or fever. H. Mirtazapine (used to treat depression) 15mg daily at bedtime During an interview with the agency director on 3/26/25 at approximately 11:00 am, the director confirmed that the plan of care did not include the correct medications. 3. Patient #9 had a Start of Care date of 12/21/2024 with an admitting diagnosis of Parkinson’s Disease (a disorder of the central nervous system that affects movement). Review of the POC for the certification period 2/19/25-4/19/25 included orders OT (Occupational therapy) 1 time a week for 6 weeks. On 3/25/25 at approximately 9:15 am, a joint visit at the Assisted Living Facility (ALF) where the patient resides, was conducted with OT #3. During the visit a medication review was conducted using the medication profile on the plan of care provided by the agency and the medication administration record (MAR) provided by the ALF. The following discrepancies were noted: A. The medication profile listed Carbidopa/Levodopa (used to treat body stiffness and tremors) 25-100mg 1 tablet 5 times a day. The ALF MAR indicated the patient was taking 4 times a day. B. The medication profile listed Aspirin (used to help prevent blood clots) 81mg every 12 hours, the ALF MAR indicated that the patient had been taking aspirin once daily. C. The medication profile listed Miralax (used to treat constipation) 17 grams 1 pack 2 times a day. This medication was not included on the ALF MAR. D. The ALF MAR listed Systane Complete eye drops (used to treat dry eyes) sol 0.6% 1 drop both eyes 6 times a day and Gabapentin (used to treat nerve pain, seizures, and to help with sleep)100mg at bedtime as needed. Neither of these medications were included on the medication profile provided by the agency. During an interview with the agency director on 3/26/25 at approximately 11:00 am, the director confirmed that the plan of care did not include the correct medications. 4. Patient #12 had a Start of Care date of 2/27/2025 with an admitting diagnosis of Essential tremor (a nervous system condition that causes rhythmic shaking) and Hypertension (high blood pressure). Review of the Plan of care for the certification period 2/27/25-4/27/25 included orders for PT 1 time a week for 5 weeks and OT 1 time a week for 1 week, 1 time every other week for 2 weeks, and 1 time a week for 3 weeks. On 3/25/25 at approximately 11:30 am, a joint visit was conducted with OT #4. During the visit, a medication review was conducted using the using the medication profile. The following discrepancies were noted: The patient’s home medications included Vitamin C (supplement) 500mg 2 times a day and Calcium (supplement) 50mg 2 gummies daily. These medications were not found on the POC medication list. During an interview with the agency director on 3/26/25 at approximately 11:00 am, the director confirmed that the medication profile did not include the correct medications.”