Universal Health Services

“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 record review and interview, the agency failed to review all medications by failing to identify all the medications taken by the patients for 2 (#4, #5) of 3 home visits conducted. The failure placed the clients at risk of over-medication, under-medication, exacerbation of disease processes, and/or adverse medications side effects. Patient #4: Record review of Patient #4’s clinical record revealed a Plans of Care dated 5/24/2024 to 7/22/2024 and 7/23/2024 to 9/20/2024. The Plan of Care indicated that Patient #4 started on the agency’s services on 3/25/2024.The Plan of Care listed Displaced Intertrochanteric Fracture of Right Femur with routine healing (a break in the upper part of the thigh bone), Sarcoidosis (unspecified disease characterized by the growth of tiny collections of inflammatory cells in areas of the body), Essential (primary) hypertension (pressure in the blood vessels is consistently too high), Blindness, one eye, unspecified eye (state or condition of being unable to see), Muscle wasting and atrophy (thinning of muscle mass), Malignant neoplasm of the bronchus or lung (cancer of the lung or large airway that leads from the windpipe), and Generalized anxiety disorder (feeling of worry, nervousness, or unease) as diagnoses. Patient #4’s clinical record contained a Medication Profile dated 7/31/2024 that listed the following medications: GoodSense ClearLax powder, daily by mouth mixed with 8 ounces of water (used to treat constipation) Lumigan 0.01% Ophthalmic Solution, 1 drop at bedtime (used to reduce pressure inside the eye) Senna 8.6 milligrams 8.6 milligrams, 2 tablets daily (used to treat constipation) Systane Hydration 0.4-0.3%, 1 drop both eyes 4 times a day (used to treat dry eyes) Xanax 0.5 milligrams daily by mouth (used to treat anxiety) Patient #4 lived at an assisted living facility, Facility X. A home visit was conducted on 8/1/2024 at 2:40 p.m. with Patient #4. Patient #4 informed the surveyor that the staff from Facility X administered Client #4’s medications. During a home visit conducted on 8/1/2024 at 2:40 p.m. to Patient #4’s home, the surveyor spoke to a medication aide and requested Patient #4’s medication administration record or a printout of the medications that Patient #4 was currently taking. The medication aide contacted Facility X’s Nurse. Facility X’s Nurse gave the surveyor a document with a list of the medications that Facility X staff were administering to Patient #4. Review of Facility X’s “Physician Order Review” document listed the following medications: Amoxicillin/Clavulanate potassium 875-125 milligrams, 1 by mouth two times a day for 7 days (used to treat infection) ordered on 7/29/2024. Benadryl Cream 2-0.1% apply topically three times a day, topical three times a day (used to treat skin irritations), ordered on 6/3/2024. Diphenhydramine- Zinc 2-0.1% apply 3 times daily as needed (used to treat skin irritations), ordered on 5/1/2024. Gabapentin 100 milligrams two times daily by mouth (used for nerve pain), ordered on 5/1/2024. Geri-Tussin DM 10-100 milligrams/5 milliliters 5 milliliters 4 times a day by mouth as needed (used to relieve cough), ordered on 6/3/2024. Milk of Magnesia 1200 milligrams/15 milliliters 15 milliliters by mouth daily as needed (used for constipation), ordered on 6/3/2024. Hydrocodone/Acetaminophen 5-325 milligrams every 6 hours as needed (used to treat pain), ordered on 5/1/2024. Lumigan 0.01% Ophthalmic Solution, 1 drop every day in the right eye at bedtime (used to reduce pressure in the eyes), ordered on 6/3/2024. Polyethylene Glycol 3350 Oral Powder, 17 Grams/scoop by mouth daily (used to treat constipation), ordered on 6/3/2024. Refresh Celluvisc Ophthalmic Solution 1% 1 drop, both eyes as needed (used to treat dry eyes), ordered 6/3/2024. Refresh Ophthalmic Solution 1.4-0.6% 1 drop each eye 4 times a day (used to treat dry eyes), ordered 6/3/2024. Senna 8.6 milligrams 2 tablets by mouth at bedtime (used to treat constipation), ordered 3/27/2024. Patient #4’s Medication Profile dated 7/31/2024 was compared to the Medication List provided by Facility X on 8/1/2024. The differences between the agency’s Medication Profile and Facility X’s Medication list were as follows: The agency’s Medication Profile did not include Benadryl cream, Gabapentin, Geri-Tussin DM, Milk of Magnesia, Hydrocodone/Acetaminophen (these medications were ordered on 6/3/2024 or prior), and Amoxicillin/Clavulanate Potassium (ordered 7/29/2024) as medications, as were listed in Facility X’s Medication list. Facility X’s Medication list for Patient #4 did not include Xanax. Patient #5: Record review of Patient #5’s clinical record revealed a Plan of Care dated 5/4/24 to 7/2/204. The Plan of Care indicated that Patient #4 started on the agency’s services on 9/7/2023. The Plan of Care listed Congestive Heart Failure (heart does not pump enough blood), Paroxysmal Atrial Fibrillation (fast, irregular heartbeat that lasts a few hours or days), Essential (primary) hypertension (pressure in blood vessels consistently too high), Acute Respiratory Failure with Hypoxia (decrease in oxygen getting to tissues) or Hypercapnia (excessive carbon dioxide in the bloodstream), Chronic Hepatitis (inflammation of the liver lasting more than 6 months), and Other Diseases of Pulmonary Vessels as Diagnoses. Patient #5’s record contained a Medication Profile dated 6/28/2024 that listed Patient #5’s current medications as follows: Acetaminophen 325 milligrams, 2 tablets by mouth every 6 hours (used to treat pain). Digox 0.25 milligrams, by mouth daily (used to treat heart failure). Finasteride 5 milligrams, by mouth daily (used to block the body’s production of a male hormone that causes the prostate to enlarge). Furosemide 40 milligrams, by mouth daily (to treat high blood pressure, heart failure, and a build up of fluid in the body). Geri-Mox Oral Suspension 30 milliliters,30 milliliters every 4 hours by mouth as needed (used to treat heartburn). Hydroxyzine Hydrochloride 25 milligrams, by mouth twice daily as needed (used to treat itching). Losartan 50 milligrams, by mouth daily (used to treat high blood pressure and heart failure) Lubiprostone 24 micrograms, twice a day by mouth (used to treat constipation). Metoprolol Succinate 50 milligrams, daily at bedtime by mouth (used to treat high blood pressure and chest pain). Milk of Magnesia 400 milligrams/5 milliliters, 30 milliliters if no bowel movement in 3 days as needed (used to treat constipation) Mucinex DM, 1 as needed by mouth (used to treat cough). Neo/Poly/Dex (Neomycin, Polymyxin, Dexamethasone) Suspension 0.1% 1 drop to eye, 4 times a day, (used to treat bacterial infection). Nitroglycerin 0.4 milligrams sublingually every 5 minutes for 3 doses as needed (used for chest pain) Pantoprazole 40 milligrams, daily by mouth (used to treat acid reflux). Polyethylene Glycol Power 17 Grams, 1 heaping tablespoon, twice a day by mouth (used to treat constipation). Potassium 20 milliequivalents take 2 tablets (20 milliequivalents) by mouth twice daily for 3 days then reduce to daily dosage (used to treat or prevent low potassium levels in the blood). Prednisone 20 milligrams 1 daily for three days by mouth then stop, (used to treat inflammation). Tamsulosin 0.4 milligrams, at bedtime by mouth (used to treat symptoms of enlarged prostate). Temazepam 15 milligrams, every night at bedtime by mouth (used for sleep problems). Warfarin 5 milligrams, 1/2 tablet on Monday, Wednesday, and Friday, by mouth (used to treat and prevent blood clots). Warfarin 5 milligrams on Sunday, Tuesday, Thursday, and Saturday by mouth. Patient #5 lived at an assisted living facility, Facility X. During a home visit conducted on 8/1/2024 at 2:40 p.m. to Client #5’s home, Patient #5 informed the surveyor that Facility X staff administered Patient #5’s medications. During a home visit conducted on 8/1/2024 at 2:40 p.m. to Patient #5’s home, the surveyor spoke to a medication aide and requested Patient #5’s medication administration record or a printout of the medications that Patient #5 was currently taking. The medication aide contacted Facility X’s Nurse. Facility X’s Nurse gave the surveyor a document with a list of the medications that Facility X staff were administering to Patient #5. Review of Facility X’s “Physician Order Review” document listed the following medications: Acetaminophen 325 milligrams, 2 tablets by mouth every 6 hours as needed, ordered on 2/6/2023. Albuterol 108 micrograms/actuation (puff), 2 puffs inhaled by mouth every 4-6 hours as needed, (used to prevent and treat wheezing and shortness of breath), ordered on 3/4/2024. Digoxin 250 micrograms by mouth daily (used to treat heart failure), ordered on 11/24/2023. Finasteride 5 milligrams, by mouth daily (used to block the body’s production of a male hormone that causes the prostate to enlarge), ordered on 11/24/2023. Furosemide 40 milligrams, daily by mouth ordered on 1/8/2024. Geri-Mox Suspension 200-200-20 milligrams/5 milliliters,30 milliliters every 4 hours as needed ordered on 2/6/2023. Hydrocortisone Cream 2.5% twice daily topical to back as needed (used to treat skin irritations), ordered on 4/20/2023. Hydroxyzine Hydrochloride 25 milligrams twice daily as needed (used to treat itching), ordered on 6/6/2024. Lidocaine Pad 5% 1 patch topical to coccyx as needed. Remove after 12 hours (used to treat pain), ordered on 10/10/2023. Losartan Potassium 50 milligrams daily by mouth, hold if systolic (maximum pressure of blood in the body when the heart contracts and pushes blood out) blood pressure less than 100 or heart rate less than 50 (used to treat high blood pressure and heart failure), ordered on 1/15/2024. Lubiprostone 24 micrograms by mouth twice daily with food (used to treat constipation), ordered on 10/9/2023. Metoprolol Succinate 50 milligrams by mouth at bedtime (used to treat high blood pressure and chest pain), ordered on 1/15/2024. Milk of Magnesia 400 milligrams/5 milliliters, 30 milliliters by mouth as needed if no bowel movement in 3 days (used to treat constipation), ordered on 2/6/2023. Neo/Poly/Dex Suspension 0.1%, 1 drop 2 times a day to the left eye until bottle is finished (treat bacterial infection), ordered on 4/3/2024. Nitroglycerin Sublingual 0.4 milligrams 1 sublingually every 5 minutes for 3 doses as needed (used to treat chest pain), ordered on 2/6/2023. Pantoprazole 40 milligrams daily by mouth (used to treat heartburn and acid reflux), ordered on 1/8/2024. Polyethylene Glycol 17 grams/scoop 1 heaping tablespoon with 8 ounces water twice daily by mouth (used to treat constipation), ordered on 1/19/2024. Potassium Chloride 10 milliequivalents, take 2 tablets (20 milliequivalents) every day by mouth (used to treat or prevent low amounts of potassium in the blood), ordered on 12/15/2023. Tamsulosin 0.4 milligrams every night at bedtime by mouth (used to treat symptoms of enlarged prostate), ordered on 11/6/2023. Temazepam 15 milligrams every night at bedtime by mouth(used for sleep problems), ordered on 1/15/2024. Warfarin 5 milligrams, 1/2 tablet by mouth on Monday, Wednesday, and Friday, ordered on 5/10/2024, Warfarin 5 milligrams by mouth on Sunday, Tuesday, Thursday, and Saturday, ordered on 5/10/2024 Client #5’s Medication Profile, dated 6/28/2024, was compared to the Medication List provided by Facility X. The differences between Patient #5’s Medication Profile and Facility X’s Medication list were as follows: The agency’s Medication Profile did not include Albuterol, Hydrocortisone cream, and Lidocaine pad as medications (these medications were ordered prior to 5/4/2024 and listed in Facility X’s Medication List). The agency’s Medication Profile listed a different frequency of administration for the Neo/Poly/Dex eye drops and listed a different dosage for Potassium Chloride compared to Facility X’s Medication List. Facility X’s Medication list for Client #5 did not include Prednisone or Mucinex. During an interview on 8/1/2024 at 1:03 p.m. with the Administrator/Supervising Nurse, the surveyor asked who was responsible for medication lists. The Administrator/Supervising Nurse informed the surveyor that it was the registered nurse. During an interview on 8/2/2024 approximately 2:36 p.m. with the Administrator/Supervising Nurse, the surveyor reviewed the home visits and discussed that the agency’s medication lists for Patient #4 and #5 differed from Facility X’s medication lists. During an interview on 8/2/2024 at 2:54 p.m. with Registered Nurse C, the survey asked how often Registered Nurse C coordinated with a facility regarding client medications. Registered Nurse C stated, “I do it at the first of every month. The Medication Aide will let me know and I get a printout.” During an interview on 8/2/2024 at 3:32 p.m. with Registered Nurse D, the surveyor asked about medication reviews. Registered Nurse D stated, “I do them at every visit, medications are reconciled at every visit, and the Medication Profile is updated.” The agency did not provide a response to change the finding and did not dispute the finding by the time the surveyor exited the agency on 8/2/2024 around 4:30 p.m. Review of the agency’s policy titled “Plan of Care,” labeled PC.35, and last reviewed on 5/2/2024 said in part; “Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems...Policy...Procedure...VII. A revised Plan of Care must reflect current information from patient’s/client’s updated comprehensive assessment...” Review of the agency’s policy titled “Medication List and Monitoring,” labeled PC.80, and last reviewed on 5/2/2024. The policy read in part; “Purpose To outline a process for ongoing medication monitoring. Policy...II. Medication monitoring will include appropriate data/information to develop an accurate patient/client medication history and a current and complete medication profile...Procedure I. The Agency will maintain a current, accurate list of all prescription and over-the-counter (OTC) medications taken by the patient/client (see the Medication Profile form)…III. The Medication Profile will also include: A. Dosage; B. Medication administration schedule, including time(s); C. Route; and D. Initial order and discontinuation dates where applicable...””

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the revised Plan of Care reflected current information regarding laboratory testing and speech therapy for 2 (#5, #7) of 7 patient records reviewed. The failure placed the patients at risk for omission or inappropriate care that could result in a negative outcome. Patient #5: Record review of Patient #5’s clinical record revealed a Plan of Care dated 5/4/24 to 7/2/204. The Plan of Care indicated that Patient #4 started on the agency’s services on 9/7/2023. The Plan of Care listed Congestive Heart Failure (heart does not pump enough blood) and Paroxysmal Atrial Fibrillation (fast, irregular heartbeat that lasts a few hours or days) as diagnoses. The Plan of Care listed Warfarin (used to treat and prevent clots) as a medication. The Plan of Care contained an order for the skilled nurse to assess Patient #5’s PT/INR (prothrombin time test/international normalized ratio -laboratory tests performed with a blood sample that measures the time it takes for the liquid portion of the blood to clot) weekly, via fingerstick or venipuncture (using a needle to extract blood from a vein). Patient #5’s clinical record did not contain evidence that Patient #5’s PT/INR level was assessed weekly. Patient #5’s clinical record did not contain results of PT/INR levels from 5/4/24 to 7/2/204. Patient #5’s clinical record did not contain a physician order dated between 5/4/2024 to 7/2/2024 that changed the frequency of the weekly PT/INR assessments. Patient #7: Record review of Patient #7’s clinical record revealed a Plan of Care dated 3/18/2024 to 5/16/2024. The Plan of Care indicated that Patient #7 started on the agencies services on 9/20/2023. The Plan of Care listed Age Related Osteoporosis (disease that cause bones to become weak/brittle, and more likely to break) as the primary diagnosis. The Plan of Care contained an order for Speech Therapy to re-evaluate and treat effective 3/18/2024. Patient #7’s clinical record did not contain evidence that a Speech Therapy evaluation and Speech Therapy treatments were provided to Patient #7 between 3/18/2024 and 5/16/2024. During an interview on 8/1/2024 at 1:03 p.m. with the Administrator/Supervising Nurse, the surveyor discussed that orders for laboratory testing and speech therapy were on the Plans of Care but no evidence in the clinical records that they had been provided. The Surveyor asked who reviewed the Plans of Care to ensure that the Plans of Care sent to the physicians were accurate to what the agency would be doing. The Administrator/Supervising Nurse informed the surveyor that the Administrator/Supervising Nurse, the Alternate Administrator/Alternate Supervising Nurse, and Quality Assurance were the individuals that reviewed the Plans of Care. The Administrator/Supervising Nurse informed the surveyor that the Administrator/Supervising Nurse will look to see what was going on with the PT/INR and speech therapy. During an interview on 8/2/2024 at 2:36 p.m. with the Administrator/Supervising Nurse, the Administrator/Supervising Nurse informed the surveyor that Patient #5’s record contained an order to discontinue the PT/INRs in October 2023, and Speech Therapy had discharged Patient #7 in March 2024. The Administrator/Supervising Nurse did not dispute that the orders for PT/INR and for speech therapy were still included in the Plans of Care. During an interview on 8/2/2024 at 2:54 p.m. with Registered Nurse C, the surveyor asked about Patient #5’s PT/INR laboratory testing and Plans of Care. Registered Nurse C informed the surveyor that a lab was providing the laboratory testing for Patient #5. Registered Nurse C was asked if Registered Nurse C developed Plans of Care. Registered Nurse C stated, “Yes. If it needs adjusting, I adjust it.” Review of the agency’s policy titled “Plan of Care,” labeled PC.35, and last reviewed on 5/2/2024 said in part; “Purpose To ensure that care provided is appropriately planned in a timely manner to meet the patient’s/client’s specific needs and problems...Policy...Procedure...VII. A revised Plan of Care must reflect current information from patient’s/client’s updated comprehensive assessment...””

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) (1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech language pathology services— (A) A registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in paragraph (g) of this section, must complete a supervisory assessment of the aide services being provided no less frequently than every 14 days; and (B) The home health aide does not need to be present during the supervisory assessment described in paragraph (h)(1)(i)(A) of this section. This Element is not met as evidenced by: Based on record review and interview, the Registered Nurse failed to complete a supervisory assessment of the aide services provided no less frequently than every 14 days for 2 (#4, #5) of 3 patient records reviewed where the patients were receiving home health aide services. The failure placed the patients at risk of inappropriate care which could result in a negative outcome. Patient #4: Record review of patient #4’s clinical record revealed a Plan of Care dated 5/24/2024 to 7/22/2024. The Plan of Care indicated that Patient #4 started on the agency’s services on 3/25/2024.The Plan of Care listed Displaced Intertrochanteric Fracture of Right Femur with routine healing (a break in the upper part of the thigh bone) as the primary diagnosis. The Plan of Care contained orders for Patient #4 to receive skilled nursing visits once each week for nine weeks, and to receive home health aide visits twice each week. Registered Nurse C provided skilled nurse visits once each week on 5/27/2024, 6/3/2024, 6/10/2024, 6/17/2024, 6/24/2024, 7/1/2024, and 7/8/2024. Registered Nurse C completed an assessment of aide services on 5/27/2024, 6/10/2024, and 7/8/2024. Registered Nurse C did not complete a supervisory assessment of the aide services provided after 6/10/2024 until 7/8/2024, resulting in 28 days between an assessment of the aide services. Patient #5: Record review of Patient #5’s clinical record revealed a Plan of Care dated 5/4/24 to 7/2/204. The Plan of Care indicated that Patient #4 started on the agency’s services on 9/7/2023. The Plan of Care listed Congestive Heart Failure (heart does not pump enough blood) as the primary diagnosis. The Plan of Care contained orders for skilled nurse visits once each week and home health aide visits twice a week. Registered Nurse C provided skilled nurse visits once a week on 5/13/2024, 5/20/2024, 5/30/2024, 6/3/2024, 6/13/2024, and 6/282024. Registered Nurse C completed a supervisory assessment of the aide services provided on 5/13/2024, 6/6/2024, and 6/17/2024. Registered Nurse C did not complete a supervisory assessment of the aide services provided after 5/13/2024 until 6/6/2024, resulting in 24 days between an assessment. During an interview on 8/1/2024 at 1:03 p.m. with the Administrator/Supervising Nurse, the surveyor discussed that the registered nurse did not complete assessments of the aide services provided to the patients, #4 and #5, every 14 days. The surveyor asked who is responsible for supervision of aide services every 14 days. The Administrator/Supervising Nurse stated, “The RN in the filed would be responsible for the 14-day aide supervision. The RNs have been educated on this.” The Administrator/Supervising Nurse informed the surveyor that the Administrator/Supervising Nurse would investigate. During an interview on 8/2/2024 at approximately 2:36 p.m. with the Administrator/Supervising Nurse, the surveyor asked whether there was evidence that aide supervision was done every 14 days, the Administrator/Supervising Nurse stated, “No, She didn’t do it.” During an interview on 8/2/2024 at 2:54 p.m. with Registered Nurse C, the surveyor discussed the supervision of aide services. Registered Nurse C stated, “I do it as its on my schedule.” Registered Nurse C informed the surveyor that it would be every two weeks, sometimes every 3 weeks. During an interview on 8/2/2024 at 3:32 p.m. with Registered Nurse D, the surveyor discussed the supervision of aide services. Registered Nurse D stated, “It is every 2 weeks, really every 14 days or before 14 days.” Review of the agency’s policy titled “Employee Supervision,” labeled HR.60, and last reviewed on 5/2/2024. The policy read in part; “Purpose To establish employee supervision practices in accordance with applicable federal and state laws and regulations. Policy I. The Agency will assign the responsibility for employee supervision to the appropriately qualified individual. II. Supervision will be performed within the time frame defined by the policy...Procedure I. The Agency will provide timely supervision of the following employees by qualified individuals: A. Home Health Aides 1. If home health aide services are provided to a patient/client who is receiving skilled nursing, physical therapy, occupational therapy, or speech-language pathology services: a. A registered nurse (RN) or other appropriate skilled professional who is familiar with the patient/client, the patient’s/client’s plan of care, and the written patient/client care instructions, must: (1) Make an onsite visit to the patient’s/client’s home no less frequently than every 14 days...””