Lehigh Valley Home 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 a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to ensure a review of all medications the patient is currently using in one (1) of the one (1) clinical records (CR) reviewed (CR#1). Agency policy was reviewed on December 16, 2024 at approximately 11:30 a.m. ‘Medication Reconciliation in the Home - HHS” ‘II. Policy’ “Lehigh Valley Home Care ... maintain a current, accurate medication profile in the clinical record. Medication profiles are updated to reflect medications the patient is currently taking and present in the home.” A review of patient CR was conducted on December 13, 2024 between approximately 12:00 p.m. - 2:30 p.m. and on December 16, 2024 between approximately 10:00 a.m. - 11:30 a.m. revealed the following. CR#1 SOC 09/18/24: Patients medication list was reviewed. The following medications were not included on the list: ‘Zinc Oxide Paste’ was listed under the ‘Treatments’ in the nursing notes for 11/06/24, 11/07/24, 11/09/24, 11/10/24, 11/14/24, and 11/27/24. ‘Micatin’ powder or other anti-fungal powder is listed under interventions in the nursing notes for 11/08/24 - 11/30/24. Nursing notes dated 11/06/24, 11/19/24, 11/27/24, 11/30/24: ‘Medication Reconciliation’ section ‘Was medication reconciliation performed this visit?’ “Yes.” An interview conducted with agency Administrator on December 16, 2024 at approximately 12:00 p.m. confirmed the above findings.”

“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 a review of agency policy, review of clinical records, and an interview with the agency Administrator, the agency failed to ensure verbal orders were authenticated and dated by the physician or allowed practitioner for one (1) of the one (1) clinical records (CR) reviewed (CR#1). Agency policy was reviewed on December 16, 2024 at approximately 11:30 a.m. Agency Policy ‘Physician Orders - Home Health Services’ ‘I. Policy’ “.... Orders will be obtained from a licensed physician (or other authorized licensed practitioner) for care and services to be provided to home health patients. Verbal orders will be taken and documented ....” ‘III. Procedure:’ (2) Verbal orders will be signed by the physician and returned to the agency within 30 days. ....” A review of patient CR was conducted on December 13, 2024 between approximately 12:00 p.m. - 2:30 p.m. and on December 16, 2024 between approximately 10:00 a.m. - 11:30 a.m. revealed the following. CR#1 SOC 09/18/24: ‘Zinc Oxide Paste’ was listed under the ‘Treatments’ in the nursing notes for 11/06/24, 11/07/24, 11/09/24, 11/10/24, 11/14/24, and 11/27/24. Documentation provided of a verbal order for a moisture barrier creme/hydration cream as needed from the physician obtained on 10/23/24. No documentation provided of obtaining a written physician order for this medication. ‘Micatin’ powder or other anti-fungal powder is listed under interventions in the nursing notes for 11/08/24 - 11/30/24. Documentation provided of a verbal order from the physician obtained on 10/13/24 and on 11/01/24 during Resumption of Care visits. No documentation provided of obtaining written physician orders for this medication after the written order dated 10/15/24 - 10/25/24 expired. An interview conducted with agency Administrator on December 16, 2024 at approximately 12:00 p.m. confirmed the above findings.”