Boone County Health Center Home Health

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. 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 profile (a real-time document used by the agency, as part of the plan of care, that lists the patient’s medications, including new and updated orders received between the certification periods) included all medication orders received by the agency for 4 of 7 patient records reviewed (Patient 2, 4, 5 and 6). The census was 13. Findings are: A. Review of the agency’s policy and procedure titled Physician Orders/Plan of Care, reviewed 8/9/24, revealed: 1. The plan of care plan (POC) was to include all medications. 2. Any interim orders were to be considered a revision of the patient’s POC. B. Review of the agency’s policy and procedure titled Medication/Prescription Orders, reviewed 5/22/25, revealed new medication orders were to be added to the medication profile. C. Review of the agency’s policy and procedure titled Medication Profile/Review, reviewed 8/1/24, revealed: 1.Medication review and documentation was to be completed at the start of care, in the Nurse’s notes if changes have occurred, with recertification, and upon discharge. 2. All new medications were to be added to the medication profile. 3. The medication profile was to be updated when the patient had a medication change. 4. Medications were to be updated as indicated by physician orders in the electronic medical record and the POC. D. Review of Patient 2’s clinical record revealed: 1.The Home Health Certification and Plan of Care (POC) for the certification period 6/10/25 through 8/8/25, and the POC’s medication profile, included Gabapentin (a medication used to treat nerve pain) 300 milligrams (mg), 2 times daily. 2. A physician’s order, dated 6/13/25, included Flexeril (a muscle relaxant medication) 10 mg, 3 times daily as needed for muscle spasms. 3. A physician’s order, dated 6/23/25, included Gabapentin 300 mg was to be decreased to 1 time daily. 4. This POC’s medication profile failed to include Flexeril and failed to decrease the frequency of the Gabapentin. E. Review of Patient 4’s clinical record revealed: 1.An Office/Clinic Note, dated 6/17/25, included: a. Acetaminophen-Hydrocodone (a medication used to treat moderate to severe pain) 325 mg-10 mg, 1 tablet every 6 hours as needed for pain. b. Docusate (a stool softener) 100 mg 1 time daily. c. Sliver Sulfadiazine (medication used to treat wound infection) 1% (percent), topically (on the skin) 2 times daily. 2. Review of the POC for the certification period 6/20/25 through 8/18/25, and the POC’s medication profile, revealed: a. Hydrocodone-Acetaminophen 10 mg-325 mg, 1 tablet every 12 hours as needed for pain. b. Colace (generic name for Colace is Docusate) 100 mg, 2 times daily. c. Sliver Sulfadiazine 1% topically, 2 times daily as needed for excoriation. F. Review of Patient 5’s clinical record revealed: 1.Hospital discharge instructions from Boone County Health Center, dated 4/15/25, included Fluticasone Nasal Spray (used to treat nasal congestion), 2 sprays in both nostrils, 1 time daily. 2. Review of the POC for the certification periods 4/17/25 through 6/15/25 and 6/16/25 through 8/14/25, and each POC’s medication profile, failed to include Fluticasone Nasal Spray. G. Review of Patient 6’s clinical record revealed: 1.An Office Visit Note, from Central City Medical Clinic, dated 3/28/25, included: a. Bacitracin Zinc ointment (used to treat wound infection), apply topically 2 times daily. b. Glucose Chewable Tablets (used to treat low blood sugar) 4 grams, 4 tablets if needed for low blood sugar. 2. The POC for the certification period of 3/31/25 through 5/29/25 and 5/30/25 through 7/28/25, and each POC’s medication profile, failed to include Bacitracin Zinc ointment and Glucose Chewable Tablets. H. During an interview on 7/22/25 at 1:45 PM, Patient 2’s caregiver, who administers medication to the patient, revealed [Gender] has decreased Gabapentin 300 mg from 2 times daily to 1 time daily. I. During an interview on 7/23/25 at 3:00 PM, the Administrator confirmed the agency staff failed to follow the agency’s policy and procedure to ensure the patient’s medication orders on the POC, and the POC’s medication profile, were accurate for 4 of 7 patient records reviewed (Patient 2, 4, 5 and 6).”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to obtain a physician’s order when 1 of 7 patients (Patient 4) reported to staff new medications they were using that were not on the Plan of Care. The census was 13. Findings are: A. Review of policy and procedure titled Physician Order/ Plan of Care, reviewed 8/9/24, revealed: 1.The Plan of Care (POC) was to be updated and maintained as part of the agency’s clinical record. 2. The POC was to include all medications. 3. Verbal orders were to be put into writing, signed, include time of the order, and dated by the person receiving the order. 4. Any interim orders are considered a revision of the patient’s POC. 5. The agency was to provide written and oral reports to the physician regarding the patient’s POC. 6. The agency’s professional staff were to review the clinical record on a continuous basis to ensure additional orders for services are present in the clinical record. B. Review of Patient 4’s clinical record revealed: 1.The POC, for the certification period 6/20/25 through 8/18/25, included orders for Skilled Nursing (SN) to assess pain at each visit. 2. Review of Skilled Nursing Visit notes dated 6/24/25, 6/26/25, 7/1/25, and 7/17/25, revealed patient reported using Voltaren cream (a medication used to treat joint pain). 3. Review of Skilled Nursing Visit note dated 7/15/25, revealed patient reported using Voltaren cream and taking Tylenol 500 (medication used to treat mild to moderate pain) 500 milligrams (mg) in between Hydrocodone doses. 4. Review of the medication profile (a real-time document used by the agency, as part of the POC, that lists the patient’s medications, including new and updated orders received between the certification periods), failed to include Voltaren cream and Tylenol 500 mg to be taken in between Hydrocodone doses. 5. There was no documentation in the clinical record for physician orders for Voltaren cream and Tylenol 500 mg to be taken in between Hydrocodone doses. C. During an interview on 7/23/25 at 3:00 PM, the Administrator confirmed the agency staff failed to obtain a physician’s order when Patient 4 reported to staff new medications they were using that were not on the POC.”