Extendicare Home Health of West TN

“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, medical record review, and interview, the agency failed to update the medication profile for 3 of 7 (Patient #1, #2, and #6) patients reviewed during home visits. The findings included: 1. Review of the agencies “Medication Management,” last revised 7/1/2024, revealed “...PURPOSE: To provide a process to ensure continuous monitoring of medications in the patient’s home...POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode...The physician is contacted immediately if any discrepancies between agency information and patient medications are found...” 2. Review of the medical record revealed Patient #1 was admitted on 5/9/2025 with diagnoses of Neoplasm of Cecum and Prostrate, Diabetes Mellitus, and Anemia. Review of the Physician Order dated 1/21/2025, revealed “...Clonidine [used to treat high blood pressure] 1 mg [milligram]...oral...2 times daily...” During an interview with Patient #1 on 6/2/2025 at 2:15 PM, stated “...It [Clonidine] was too strong…has been taking one tablet…not two...” Observations of Patient #1’s medications on 6/2/2025 at 2:17 PM, revealed Patient was taking Aspirin (medication used to treat heart conditions) 81 mg one daily and Omeprazole (medication used to treat stomach acid) 40 mg one daily. Review of the Physician Orders revealed the agency did not have orders in Patient #1’s medical record for these medications. During an interview on 6/2/2025 at 2:21 PM, Pt. #1 confirmed he had been taking these medicines for a long time. During an interview on 6/2/2025 at 2:22 PM, with Licensed Practical Nurse (LPN) #1, confirmed the medications were not listed on Patient #1’s medicine list and confirmed she would notify his physician. 3. Review of the medical record revealed Patient #2 was admitted to the agency on 4/29/2025 with diagnoses Displaced Fracture of Left Tibia, Fibromyalgia, and Falling. Observations of Patient #2’s medications on 6/2/2025 at 2:45 PM, revealed Patient was using Daily Immune Support with Elderberry (supplement). Patient #2 confirmed she had been taking one a day for years. During an interview on 6/2/2025 at 2:50 PM, the Physical Therapist Assistant (PTA) #1 confirmed the supplement was not on Patient #2’s medicine list. 4. Medical record review revealed Patient #4 was admitted to the agency on 2/12/2025 with diagnoses of Pressure Ulcer of Left Buttock, Stage 2, Hypertension, and Venous Insufficiency. Observations of Patient #6’s medications on 6/2/2025 at 4:30 PM, revealed Allopurinol (medication used to treat gout) 100 mg one daily was filled on 4/10/2025 and Rosuvastatin (a medication used to lower cholesterol) 10 mg one tablet daily was filled on 5/12/2025 was not listed on the medicine list. During an interview on 6/2/2025 at 4:31 PM, with Patient #6’s daughter confirmed Megestrol was never picked up from the pharmacy, and she was not taking Vitamin D3 supplement. During an interview with Registered Nurse (RN) #1, confirmed the home medication record was not updated. During an interview on 6/4/2025 at 11:00 AM, the Executive Director confirmed a drug regimen review should be performed at each visit and medicine list updated.”

“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 policy review, record review and interview, the facility failed to follow the plan of care and failed to address pain for 1 of 12 (Patient #11); the Home Health Agency also failed to follow the visit schedule for 1 of 17 (Patient #13) sampled patients reviewed. The findings included: 1 Review of the facility’s “PAIN ASSESSMENT” policy (2/1/2024) revealed, “...The clinician...to assess pain at the present time in the patient and to initiate pain relief measures in the Plan of Care (POC) during each skilled visit. A score of 7 or greater on any of the pain assessment tools...is indicative of severe pain, which will require physician/authorized practitioner notification and patient appropriate interventions...” 2 Review of the facility’s “PLAN OF CARE (POC)” policy (9/1/2024) revealed, “...Each patient has an individualized Plan of Care (POC) developed in consultation with the patient, physician or authorized practitioner, and staff that integrates comprehensive assessment findings to address patient problems, needs, and goals...When a missed visit occurs altering the POC…the agency will report a missed visit…within 3 calendar days…” 3. Medical record review for Patient #12 revealed a Start of Care (SOC) date of 4/7/25 with diagnoses which included Type 2 Diabetes and Hypertensive Chronic Kidney disease. Patient #12’s POC dated 4/7/25 through 6/5/15 revealed, “...When vital signs are obtained licensed professional to report vital signs falling outside the following established parameters...pain> [greater than] 7...” Review of a 5/22/25 skilled nurse (SN) note revealed, “...Patient stated his head and neck are hurting worse today and nothing ever helps with the arthritis pain. Patient reported 10/10 [on pain scale of 0-10] but refuses to go to er to be evaluated...” There was no documentation the SN notified the physician of the pain level greater than 7, which was outside ordered parameters. There was no documentation the SN provided interventions to address pain level greater than 7. In an interview on 6/4/25 at 10:00 AM, the facility’s Executive Director verified the physician should have been notified of the pain level. The Executive Director verified the SN should have addressed the pain level with appropriate interventions. 4. Medical record review for Patient #13 revealed a SOC date of 6/27/2024 with a diagnosis which included Chronic Obstructive Pulmonary Disease, Heart Failure, and Glaucoma. Patient #13’s 6/27/2024 through 8/25/2024 POC revealed Skilled Nurse (SN) 1 time per week for 1 week (1WK1), 2WK2, 1WK6, SN X 2 as needed (PRN) Chronic Obstructive Pulmonary Disease (COPD), SN 2 PRN Cardiac Complications, SN 2 PRN Wound Complications, Physical Therapy (PT) effective 6/30/2024 1WK8, Occupational Therapy (OT) 1WK1, Master Social Worker (MSW) effective 6/30/2024, Home Health Aid(HHA) effective 6/30/2024 1WK8. Record review for Patient #13, revealed no SN visit was made for the week of 7/14/2024- 7/20/2024. There was no documentation the physician was notified of the missed visit. Record review for Patient #13, revealed no HHA visits for the weeks of 7/7/2024-7/13/2024, 7/14/2024-7/20/2024, 7/21/2024-7/27/2024, and 7/28/2024-8/3/2024. There was no documentation the physician was notified of the missed visits. Record review for Patient #13, revealed an ordered dated 6/30/2024 for OT. There was no documentation the visit was made, or the physician was notified of the missed visit. In an interview on 6/4/25 at 10:12 AM, the facility’s Executive Director verified the SN, HHA and OT visits were missed for Patient #13. The Executive Director confirmed the visits were missed and the physician should have been notified of the missed visits.”