Eventide Home 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 record review, policy and procedure review, and staff interview, the agency failed to ensure the patient’s medication orders on the Plan of Care and the medication profile (a real-time document used by the agency that lists the patient’s medications), were accurate, for 5 of 17 patient records reviewed (Patient 3, 5, 6, 7, 12). The census was 251 (146 in the Lincoln office, 58 in the Grand Island branch office and 47 in the York branch office). Findings are: A. Review of the agency’s policy and procedure titled Medication Profile 4-024.1, updated 1/24/24, revealed: 1. All patients on service will have a current, accurate medication profile in the clinical record. 2. Medication profiles will be updated with each change to reflect current medications, new, changed, and/or discontinued medication. 3. A drug regime review will be performed at the time of admission, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. 4. A drug regime review did not include medication discrepancies between the physician’s orders and what the patient is currently taking. 5. Any conclusions and findings of patient medication use, or monitoring, should be communicated to the physician. B. Review of Patient 3’s clinical record revealed: 1. The Order Summary Report from Hillcrest Firethorn to the agency, dated 11/7/2024, included orders for Acetaminophen (used to treat mild to moderate pain), and Cal-Gest (used to treat indigestion). 2. An order from the patient’s primary care provider to the agency, dated 11/20/24, included orders to hold Furosemide (used to treat edema) for 4 days. 3. The Home Health Certification and Plan of Care (POC) for the certification period 11/10/24 through 1/8/25 and the medication profile did not include Acetaminophen and Cal-Gest. 4. Furosemide was not discontinued on the medication profile. 5. During interview on 12/4/24 at 11:00 AM, Patient 3 confirmed that [gender] was not taking Furosemide. 6. There was no documentation in the clinical record of medication reconciliation, of the medications discrepancies, with the physician. C. Review of Patient 5’s clinical record revealed: 1. Transfer/Discharge/Active Orders from Madonna Rehabilitation Specialty Hospital-Lincoln, to the agency, dated 10/23/24, included orders: a. Melatonin (used to aid with sleep), Pantoprazole (used to treat heartburn), Ondansetron (used to treat nausea), Simethicone (used to treat gas) and Cathflo Activase (use to dissolve blood clots). b. Levothyroxine (used to treat low thyroid function) 175 mcg (micrograms), 2 tablets daily. c. Metformin (used to treat diabetes) 850 mg (milligrams) with breakfast and dinner. 2. The POC for the certification period 10/24/24 through 12/22/24, and the medication profile revealed: a. Melatonin, Pantoprazole, Ondansetron, Simethicone, and Cathflo Activase were not listed. b. Levothyroxine 175 mcg, 1.5 tablets, on Sunday and Thursday, and 1 tablet, on Monday, Tuesday, Wednesday, Friday, and Saturday. c. Metformin 500 mg, 2 times daily. 3. During an interview at 12/5/24 at 1:00 PM, the Administrator confirmed, the agency does not administer Cathflo Activase. 4. There was no documentation in the clinical record of medication reconciliation. 5. There was no documentation of communication with the physician in the clinical record to discontinue the order for the agency to administer Cathflo Activase. D. Review of Patient 6’s clinical record revealed: 1. An order from the physician at Lincoln Internal Medicine Associates to the agency, on 12/5/24, included orders: a. Increase Furosemide from 40 mg twice daily to 80 mg twice daily. b. Increase Potassium (supplement) from 10 mEq (milliequivalent) twice daily to 20 mEq twice daily. 2. The medication profile dated 12/3/24 revealed: a. Fursemide 40 mg twice daily. b. Potassium 10 mEq twice daily. 3. The agency failed to update the medication profile when new orders were received. E. Review of Patient 7’s clinical record revealed: 1. Order Summary Report from Heritage Crossings to the agency, on 10/28/24 included orders for: a. Alphagen P Ophthalmic Solution (used to treat glaucoma), Glucagon (used to treat low blood sugar), Ibuprofen (used to treat mild to moderate pain) Ondansetron, Polyethylene Glycol (used to treat constipation), Trazadone (used to treat depression), Tums (used to treat heartburn), and Zoloft (used to treat depression). b. Novolog Insulin (used to treat diabetes) 7 units (measurement of insulin) before breakfast, and 5 units before lunch and supper. 2. The POC for the certification period 11/1/24 through 12/30/24 and the medication profile did not include Alphagen P Ophthalmic Solution, Glucagon, Ibuprofen, Ondansetron, Polyethylene Glycol, Trazadone, Tums, or Zoloft. 3. The POC for the certification period 11/1/24 through 12/30/24 and the medication profile revealed Novolog Insulin 5 units before each meal. 4. There was no documentation in the clinical record of medication reconciliation, of the medication discrepancies, with the physician. F. Review of Patient 12’s clinical record revealed: 1. The Order Summary Report from Tabitha Nursing and Rehabilitation Center to the agency, dated 10/15/24, included orders for: a. Insulin Degludec (used to treat diabetes) 16 units daily. b. Insulin Degludec 86 units at bedtime. c. CBD Gummy (used to decrease anxiety). 2. The POC for the certification period 10/17/24 through 12/15/24 and the medication profile revealed: a. Tresiba Insulin (same as Insulin Degludec) 88 units twice daily. b. CBD gummies were not included. 3. There was no documentation in the clinical record of medication reconciliation, of the medication discrepancies, with the physician. G. During an interview on 12/12/24 at 4:30 PM, the agency Administrator confirmed the medication profiles for Patients 3, 5, 6, 7, and 12 were not accurate.”