Centra Home Health

“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 clinical record review, interview and agency procedure, it was determined the agency failed to ensure accurate and complete medication lists were documented in one (1) of (17) clinical records reviewed in the survey sample (Clinical records for Patient #: 1). The findings: 1. The clinical record for Patient #1 was reviewed for the period of February 06, 2025 to April 06, 2025. The plan of care indicated Skilled Nurse visits once a week for one (1) week, two (2) times for three (3) weeks and once a week for two (2) weeks. In addition, the plan of care indicated Physical Therapy once a week for one (1) week, tow (2) times for seven weeks and once a week for one (1) week. A Skilled Nursing and Physical Therapy visit of March 18, 2025 both indicated the patient went to the emergency department on March 14, 2025 and was treated for a urinary traction infection with a new antibiotic to be picked up by the patient’s child this day. The clinical record indicated two (2) more Physical Therapy visits on March 21, 2025 and March 24, 2025 with no indication of a new antibiotic documented in the notes or medication list. On March 27, 2025, a Skilled Nurse visit did not indicate a new antibiotic in the notes or medication list. On April 02, 2025 at 4:05 PM, Staff Member #10 was called and revealed writing the patient’s son was to pick up the medication but the next visits of March 21, 2025 and March 24, 2025, were assumed nursing would get the medication update. On April 02, 2025 at 4:15 PM, Staff Member #11 was called and revealed by the time nursing visit was made, the patient had finished the antibiotic and the bottle was thrown away. The agency’s medication list failed to contain the new antibiotic medication. On April 04, 2025 the agency’s process for the medication profile was reviewed as follows: “Home Health Medication Profile-MM.01.01.01” with a revision date of August 07 2023. The process indicated during subsequent home visits, the medication profile will be updated and used as a care planning and teaching guide to ensure that the patient and family/caregiver understand the medication regimen throughout care. This includes but will not be limited to: A. Using the medication profile to evaluate the use of the drugs in the home setting. B. Using the medication profile to teach purpose of medication, dosages, routes administration times, side effects and contraindications. C. Using the medication profile as a communication tool for other clinicians/professionals involved in the care. The agency failed to update the patient’s medication profile as noted above.”

“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 clinical record review and interview, it was determined the agency failed to ensure the physician was notified of the patient’s condition that may suggest outcomes are not being met or changes are needed in the plan of care. Specifically, the physician was not notified about out of range vital sign parameters for one ()1 of (17) clinical records reviewed in the survey sample (Clinical record for Patient #: 12). The findings: 1. The clinical record for Patient #12 was reviewed for the certification period of January 03, 2025 to March 03, 2025. The patient’s plan of care contained a primary diagnosis of Hypertensive heart and chronic kidney disease with heart failure and orders as follows: Perform vital signs each visit, notify Provider if systolic blood pressure less than 80 and if a cardiac patient, notify Provider of systolic blood pressure less than 90. The clinical record on January 16, 2025 indicated a Skilled Nursing report of patient dizzy and blood pressure dropped from 120/72 to 88/58. In addition, Physical Therapy made a visit on the same day of January 16, 2025 and indicated the patient’s blood pressure of 88/50 while standing and feeling light headed. The visits on January 16, 2025 revealed a systolic blood pressure less than 90 and a primary diagnosis as a cardiac patient. On April 03, 2025 at 4 PM, it was revealed Staff Member #12 was on PTO (paid time off) and was unavailable for interview. On April 03, 2025 at 4:13 PM, Staff Member #13 revealed the doctor was aware of the patient’s orthostatic issues but can’t remember all the incidents. On April 04, 2025 the agency’s process for physician communication was reviewed as follows: “Home Health Physician Communication- PC.02.02.01g” with a revision date of August 07 2023. The process indicated to maintain ongoing communication with the physician, as appropriate , to ensure safe and appropriate care for the patient. 1. Contact to the patient’s Signatory/Primary Physician will occur. The clinician involved in the activity is ultimately responsible for ensuring the communication but communication may enlist assistance and coordination from other team member. B. When there are changes in the patient’s condition or adverse event. 2. All conferences or attempts to communicate with Signatory/Primary Physician will be documented in the clinical record. The clinical record failed to notify the physician of the above out of range parameters.”