Choice Homecare of Oklahoma

“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 and interview, the agency failed to conduct a review of all medications the patient was currently using to identify adverse effects and drug reactions, side effects, and duplicate drug therapy for four (#1, #4, #5 and #7) of seventeen (#1- #17) records reviewed. Pt #1 During a home visit on 04/16/25, the current client medication profile showed Humalog U-100 Insulin to be taken 1 Unit as directed subcutaneous. On 04/16/25 at 1:30 PM, Pt#1 stated he had Type II Diabetes Mellitus, takes Metformin but does not take Insulin. Pt #4 During a home visit on 04/17/25, the current client medication profile included Humalog Kwikpen U-100 Insulin to be taken 1 ml 3 times daily subcutaneous. No sliding scale instructions were included on the client medication profile. Further review of the client medication report failed to include Torsemide found in the home and prescribed on 03/10/25. Documentation showed the medication profile was last reviewed by SN #1 on 02/25/25. On 04/17/25 at 08:30 AM, Pt#4 stated they had Type II Diabetes Mellitus and takes Insulin on a sliding scale, and takes Furosemide for her fluid and showed a bottle with prescription dated August 2024. Pt #5 During a home visit on 04/17/25 at 11:30 AM, the current Client Medication Profile included Torsemide 20 mg 1 tablet daily. Documentation showed no use of Ozempic and was last reviewed by SN #22 on 04/02/25. On 04/17/25 at 11:30 AM, Pt#5 stated Torsemide was increased to 80 mg after their recent hospitalization of 3/31/25. Pt #5 also stated they lost weight taking Ozempic for the past 2 months. Pt #7 Review of the current Client Medication Profile on 04/17/25 showed multiple duplicate medications and no evidence a SN conducted a drug regimen review since the SOC review conducted by SN1 on 04/02/25. During an interview on 04/18/25 at 10:15 AM, Staff A explained the agency process regarding medication reports and stated the SN staff failed to review medications to ensure current and accurate medication reports for Pts #1, #4, #5 and #7.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview, the agency failed to promptly alert the physician of a change in the patient’s condition for two (#5 and #12) of seventeen (#1- #17) records reviewed. Pt #5 A review of the POC showed a recertification period 03/20/25 - 05/18/25 and a diagnosis of Congestive Heart Failure. SN Visit weight documentation on 4/2/25 showed 303 pounds. A SN visit on 4/04/25 showed 308 pounds, a five- pound weight gain in two days. Further review failed to provide evidence the physician was notified of the weight- gain. No weight parameters were identified on the POC. Pt #12 A review of the POC for Patient #12 showed an initial certification period of 02/22/25 - 04/22/25 and a diagnosis of Congestive Heart Failure. A SN Visit note dated 3/4/25 showed a weight of 123.6 pounds and a SN Visit note dated 3/20/25 showed 132.2 pounds, a nine-pound weight gain in two weeks. Further review failed to provide evidence the physician was notified of the weight-gain. No weight parameters were identified on the POC. During an interview on 04/18/25 at 10:15 AM, Staff A stated the agency failed to notify the physician of significant weight changes for Pts #5 and #12.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on record review and interview, the agency failed to provide a completed transfer summary to the facility within 2 business days of becoming aware of an unplanned transfer for one (#16) of five (#13- #17) discharged records reviewed. A review of the POC for Patient #16 for recertification period 01/04/25 - 03/04/25 showed a transfer to a short-term general hospital on 01/18/25 and a discharge date of 02/11/25. Further review failed to provide evidence a transfer summary was sent to the facility as required. During an interview on 04/18/25 at 10:15 AM, Staff A stated the agency failed to send a completed transfer summary to the facility within 2 business days of becoming aware of an unplanned transfer for Pt #16.”