Nhc Homecare Laurens

“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 interview and record review, the facility failed to follow their policies and procedures to ensure that there are no discrepancies between medications listed on the Medication Administration Record and the medications the patient is actually taking for 3 of 7 applicable patients. (Patient #13, #14, and #16). Record review of facility’s policy titled, “NHC Homecare Clinical Best Practices,” dated 2/2021, showed medication reconciliation will occur on every SN and therapy visit to include medication review and report of any new medications. Observation in Patient #16’s home on 03/19/2024 from 10:05 AM to 11 AM showed Levothyroxine 100 mcg capsule by mouth once a day and Levothyroxine 50 mcg capsule by mouth once a day. Patient #16 stated confusion over which dosage should be taken and reports 2 different physicians gave orders for the levothyroxine. Patient #16 stated that no longer taking Omeprazole 20 mg 1 capsule by mouth daily but as needed. During an interview on 03/20/2024 at 10:40 AM, Administrator, stated that the visit note from the Certified Occupational Therapy Assistant (COTA) for 03/19/2024 reports call to Registered Nurse (RN) case manager to clarify orders. Findings included: Observation on 03/19/2024 at 10:00 AM showed Patient #13 with a diagnosis of Hypertension had discrepancies between medications listed on the Medication Administration Record (MAR) and medicines the patient was actually taking. Amitriptyline 25 milligrams daily; Benztropine 1 milligram twice per day; Benztropine 2 milligrams twice per day are on the MAR but patient is not taking the drugs per the brother/caregiver. Atorvastin 20 milligrams at bedtime; prednisone 5 milligrams daily; Metformin 500 milligrams daily; Ibuprofen 400 milligrams every 8 hours are taken by the patient but are not on the MAR. The visiting Certified Occupational Therapist Assistant (COTA) responded/confirmed “The medications are hard to keep up with”. Observation on 3/19/2024 at 9:00 AM for Patient #14 with a diagnosis of Post Surgical Orthopedic Procedure showed there were discrepancies between medications listed on the Medication Administration Record (MAR) and medicines the patient was actually taking. Pregabalin 25 milligrams twice daily on the MAR is not taken by the patient. Over the counter drugs Biotin & D3 daily; Aspirin 350 milligrams daily: Prednisone 2.5 milligrams are being taken by the patient but are not on the MAR. The visiting Physical Therapy Assistant (PTA) #4 responded/confirmed “I didn’t know that”.”

“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 interview and record review, the hospice failed to notify the physician of staff missed visits for 3 of 17 patient records reviewed. (Patient #6, #10 and #15) The findings are: Review of Patient #6’s medical record on 03/19/2024 at 1:31 PM showed missed visits notes by the Physical Therapist Assistant (PTA) on 11/03/2023 and by the Certified Occupational Therapy Assistant (COTA) on 11/16/2023 and 11/22/2023. There was no documentation the physician was notified of the missed visits. During an interview on 03/19/2024 at 11:15 AM, Clinical Manager #3 stated that did not find any documentation of faxes to the physician. Review of Patient #10’s medical record on 03/19/2024 at 2:35 PM showed missed visit notes by OT on 01/25/2024, Licensed Practical Nurse (LPN) on 01/25/2024, and Physical Therapy (PT) on 01/24/2024. There was no documentation the physician was notified of the missed visits. During an interview on 03/20/2024 at 10:22 AM, Administrator stated that there was no documentation but missed visits are usually faxed to all physicians. Review of Patient #15’s medical record on 03/19/2024 at 12:00 PM showed missed visits note by the COTA on 02/23/2024. There was no documentation the physician was notified of the missed visits. During an interview on 03/20/2024 at 10:37 AM, Administrator stated that there was no documentation but missed visits are usually faxed to all physicians.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on record review and interview, the home health agency failed to ensure all physican orders were followed for 3 out of 17 patients (Patient #2, #8 and Patient #10). Findings included Record review for Patient #8 showed Physical Therapy had physician orders for Physical Therapy (PT), 2 visits every week for 4 weeks. There is no documentation for the second weekly visit in the third week. During an interview on 3/20/2024 at 2:30 PM with the Nurse Clinical Manager #2 this information was confirmed. Review of Patient #2’s medical record on 03/18/2024 at 12:27 PM showed physician order for evaluation by Occupational Therapy (OT). There is no documentation of an evaluation performed by OT. During an interview on 03/20/2024 at 12 noon, Clinical Manager #2 stated that it should have been done. Review of Patient #10’s medical record on 03/19/2024 at 2:35 PM showed physician orders for evaluation by OT. OT documents missed visit on 01/25/2024. Documentation for missed visit does not give reason for missed visit. There is no follow up for OT evaluation performed. During an interview on 03/20/2024 at 10:22 AM, Administrator stated that did not find any documentation why follow up evaluation was not completed and verified missed visit note empty of documentation.”