Nhc Homecare Somerville

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on policy review, medical record review, and interview the agency failed to ensure weekly wound measurements were documented in the medical record for 1 of 3 (Patient #9) sampled patients with wounds. The findings included: 1. Review of the agency’s “Documentation of Wounds and Wound Care” policy revised 5/2024 revealed, “...Documentation of Wound Assessments and Care...Each wound is measured and documented at least weekly...” 2. Medical record review for Patient #9 revealed a Start of Care date of 3/13/2026 with diagnoses which included a Stage 3 Pressure Ulcer of the left heel and a Stage 2 Pressure Ulcer of the Sacral area. Review of the Visit Note Reports dated 3/13/2026 through 4/27/2026 revealed no documentation the Patient’s sacral wound was measured the weeks of 3/15/2026, 3/22/2026, and 3/29/2026. 3. During an interview on 5/5/2026 at 2:07 PM, the Regional Administrator (RA) verified the sacral wound wasn’t measured the weeks of 3/15/2026, 3/22/2026, and 3/29/2026. The RA stated wounds should be measured once a week.”

“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 policy review, observation and interview, the facility failed to ensure medications were accurately documented in the medical record for 3 of 5 (Patient #1, #2, and #9) sampled patients observed during home visits. The findings included: 1. Review of the agency’s “Clinical Services- Nursing Medication Review and Reconciliation” policy revised 5/2022 revealed, “... Purpose: To establish processes that maximize patient safety and outcomes related to medications and to comply with related state and federal regulations and clinical best practice. Policy:…Medication compliance, effects and changes are assessed at every skilled visit…Medication review and reconciliation is a multi-faceted and on-going process performed via interview and observation techniques. It included: Eyes on- review of all prescription and non- prescription medications the patient is currently using… “ 2. Medical record for Patient #1 revealed a Start of Care (SOC) date of 4/13/2026 and a primary diagnosis of a fracture of the right femur. Observations in Patient #1’s home on 5/5/2026 at 1:30 PM, revealed the following medications were in the Patient’s home, but were not included on the Client Medication Report: Mucus Relief over the counter (OTC) 400 milligram (mg) once a day Centrum Men 50 plus daily vitamin (OTC) once a day Mucinex DM Maximum (OTC) 1 tablespoon daily Advil (OTC) one tablet once a day During an interview on 5/5/2026 at 1:33PM, Patient #1 confirmed he was taking the above medications. Patient #1 verified the above medications were not new medications. 3. Medical record review for Patient #2 revealed a SOC date of 4/17/2026 and a primary diagnosis of Acute Cystitis. Observations in Patient #2’s home on 5/5/2026 at 9:17 AM, revealed the following medications were in the Patient’s home, but were not included on the Client Medication Report: Amlodipine Besylate 5 mg by mouth once a day Tramadol 50 mg by mouth every 8 hours as needed for pain Metformin HCL ER 500 mg by mouth once a day Dutasteride 0.5 mg by mouth once a day Vitamin D3 25 micrograms (mcg) by mouth every Monday Eliquis 2.5 mg by mouth once a day Pilocarpine 1 percent (%) eye drops, no instructions on the bottle During an interview on 5/5/2026 at 9:25 AM, Patient #2’s niece confirmed the Patient was taking the above medications. The following medications were included on the Client Medication Report but were not in the Patient’s home: Myrbetriq 50 mg ER by mouth once a day Xarelto 15 mg by mouth once a day During an interview on 5/5/2026 at 9:25 AM, Patient #2’s niece stated Patient #2 was no longer taking the Myrbetriq or Xarelto. 4. Medical record review for Patient #9 revealed a SOC date of 3/13/2026 and diagnoses which included a Stage 3 Pressure Ulcer of the left heel and a Stage 2 Pressure Ulcer of the Sacral area. Observations in Patient #9’s home on 5/5/2026 at 11:14 AM revealed the following: Pitavastin 2 mg by mouth once daily. The Client Medication Record showed 1 mg daily. Losartan 50 mg by mouth twice a day. The Client Medication Record showed 2 tablets (a total of 100 mg) twice a day. The following mediations were included on the Client Medication Record, however, Patient #9 stated she was no longer taking them: Acetaminophen 650 mg by mouth once a day Aspirin 81 mg by mouth once a day Biotin 1 mg by mouth once a day Bumetanide 0.5 mg by mouth twice a day Calcium 600 mg + Vitamin D3 5mcg by mouth twice a week Fish Oil 1,000 mg by mouth once a day Garlic 1,000 mg by mouth once a day Lyrica 75 mg by mouth at bedtime Magnesium Oxide 400 mg by mouth twice a week Naproxen Sodium ER 375 mg, 2 tablets by mouth daily Oxycodone 5 mg by mouth every 4 hours as needed for pain Vitamin E mixed 400 unit capsule by mouth twice a week The following medications were being taken by Patient #9, but were not included on the Client Medication Record: Wound Vite 2 capsules by mouth once a day Vitamin C 1,000 mg by mouth once a day During an interview on 5/5/2026 at 11:17 AM, Registered Nurse #1, Patient #9 and her husband verified the above information. 5. During an interview on 5/6/2026 at 9:07 AM, the Administrator verified all clinical staff should assess and document any medication changes in the medical record, at each home visit.”