UPMC Home Healthcare of Central Pennsylvania

“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 and procedure, patient observations visits (OBV), medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking, address potential adverse effects, drug reactions, ineffective drug therapy, significant side effects and drug interactions for three (3) of seventeen (17) MR’s reviewed (MR4-OBV6, MR7-OBV3, MR10). Findings Included: Review of agency policy and procedure on 3/13/2024 at approximately 12:45 PM revealed, “Category: M MEDICATIONS MEDICATION MANAGEMENT RECONCILIATION… Accurate and complete reconciliation of medications should occur across the continuum of care…EQUIPMENT Patient medication(s) and delivery method, Discharge summary, Agency patient Medication List, patient documentation record access (Medication Profile) PROCEDURE…4. All ordered medications must be listed accurately on a paper list and entered electronically into the medical record…9. If needed, create the Patient Medication List that includes ALL medications the patient is taking. The sources of information for the Patient Medications List should include: a. Patient pill containers, prescriptions, OTC medications, vitamins, herbal supplements, topicals, IV medications/flushes, eye drops. b. Hospital discharge list of medications, if applicable, and referral information. C. Medications listed in the electronic record from previous admissions. d. Medication lists created by the patient. e. Information elicited from patient by questioning i.e. medications they may take occasionally, or medications kept in different parts of the home…f. Information about medications taken infrequently i.e., B12, Fosamax. g. Medications not reordered following a change in the plan of care (i.e., following a hospitalization). 14.Assess the patient’s allergy history. If the patient has a known or suspected allergy/adverse reaction history or sensitivity to a medication, I will not be administered. Contact the physician, PA or CRNP for further direction. (Therapy staff refer to a nurse) for assistance…17. Check for adverse interactions and notify physician, PA, or CRNP if severity Level 1 drug interaction is identified. Therapy staff refer to a nurse for assistance…” Review of (OBV6 MR4) was conducted on 3/14/2023 at approximately 1:55 PM, a review of the plan of care listed the start of care 3/1/2024 for a current certification period starting 3/1/2024 and ending 4/29/2024. The primary diagnosis was urinary tract infection, site not specified. The agency “Medication profile” dated 3/12/2024 was compared to the facilities “PHYSICIAN’S ORDERS date printed 3/14/2024. The following medication was not listed on the agency medication profile. “POT CL MICRO TAB 10MEQ ER…TAKE 1 TABLET BY MOUITH ONCE DAILY…3/6/2024.” Review of (OBV3-MR7) on 3/14/2024 at approximately 10:28 AM revealed, a review of the plan of care with a start date of 1/12/2023 and a current certification period starting 1/19/2024 and ending 3/18/2024. The primary diagnosis was other complications of procedures, not elsewhere classified. The home health certification and plan of care and medication profile did not list one of two patient allergies. Allergies listed on the agency medication profile printed 3/12/2024 and the plan of care was “Lisinopril.” Listed on the agency “Patient Information Facesheet… Allergies metoprolol…lisinopril” Review of MR10 on 3/12/2024 at approximately 1:48 PM revealed, a review of the plan of care with a start date of 3/7/2023 and a current certification period starting 3/1/2024 and ending 4/29/2024. The primary diagnosis was acute tracheitis without obstruction. The home health certification and plan of care and medication profile was compared to the medical record document “Continuity of Care Document 2/26/2023.” The agency documentation did not list three (3) of four (4) patient allergies. Allergies listed on the agency medication profile printed 3/11/2024 and the plan of care was “cefepime.” Listed on the continuity of care document was “Allergies, Adverse Reactions, Alerts…propofol…cefepime1…Lactated Ringers Irrigation…Plasma-Lyte…” An exit interview with the senior director of regional home health services, vice president of clinical operations, manager of quality and compliance, director of clinical operations. Via conference call the following staff joined the exit conference: president of home health and hospice, senior director of quality and compliance, director of quality and compliance, senior manager of quality and compliance, physical therapy director rehab services, occupational therapy coordinator, (two) 2 quality and compliance coordinators and (nine) 9 clinical managers on 3/15/2024 at approximately 11:55 AM confirmed the above findings.”