Interim Healthcare of Wausau

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on record review and interview, the agency staff failed to assess the patient’s wound to include wound measurements in accordance with physician orders and agency policy in 2 of 3 wound patients (Patient #6 and #10) in a total of 10 patient records reviewed. Findings include: Review of the agency policy, titled “Developing a Plan to Meet Patient/Client Needs,” dated 4/21/2021, revealed: “Wound: The clinician measures the wound(s) weekly and documents the results.” Record review of Patient #6’s “Home Health Certification and Plan of Care” orders (dated 10/11/2023 to 12/09/2023) revealed in part, “SN (Skilled Nurse): 2 times a week for 8 weeks. SN to perform assessments with emphasis on wound care (right buttock) and heart failure. SN indicated for wound care management based on physician orders due to the inherent complexity of wound. SN to assess wound progression or decline.” Record review of Patient #6’s SN visits from 10/11/2023 to 11/06/2023 revealed two visits were made the week of 10/15/2023, with no documented evidence of measurement of the buttock wound. Record review of Patient #10’s “Home Health Certification and Plan of Care” orders (dated 08/15/2023 to 10/03/2023) revealed in part, “SN (Skilled Nurse): 1 time a week for 9 weeks. SN to perform complete physical assessment each visit with emphasis on wound care to left great toe. SN indicated for wound care management based on physician orders due to the inherent complexity of wound. SN to assess wound progression or decline.” Record review of Patient #10’s SN visits from 08/15/2023 to 10/03/2023 revealed the weeks of 08/20/2023 and 08/27/2023, two visits were made each week (08/22/2023, 08/25/2023, 08/29/2023, and 09/01/2023) and no evidence of documented measurement of the left great toe wound. During an interview on 11/07/2023 from 1:45-2:15 PM, Administrator A stated, “Wound measurements should be done weekly.” Record review findings for Patients #1 through #10 were reviewed and confirmed with Administrator A on 11/07/2023 from 1:45 PM to 2:15 PM.”

“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, observation and interview, the agency failed to maintain an accurate medication list as compared to what the patient is taking and/or ordered in 3 of 4 patient home visits observed (Patient #1, #3, and #4) in a total of 10 home health patient records reviewed. Findings include: Review of agency policy and procedure titled “Initial Comprehensive Assessment” dated 04/02/2021 revealed in part, “Policy: Initial comprehensive assessments are conducted in accordance with applicable law and regulation. Procedure: Assessment of Adult Patients Requiring Skilled Care: 2. The RN (Registered Nurse), PT (Physical Therapist), OT (Occupational Therapist) or SLP (Speech Language Pathologist) documents the findings of the initial comprehensive assessment on paper or electronically in standardized format. a) includes the elements of the following documents: i) the Medication Profile.” Record review of Patient #1’s “Home Health Certification and Plan of Care” medication orders dated 09/27/2023 – 11/25/2023 revealed “Metoprolol Succinate 50mg (milligrams) oral capsule 1 tablet daily by mouth. Amlodipine 5mg oral 1 tablet daily by mouth.” A home visit for Patient #1 was conducted at the patient’s residence on 11/06/2023 from 1:20 PM to 1:55 PM. During the home visit, observed RN B ask Patient #1 if there were medication changes. Patient #1 replied, “No.” Upon cessation of home visit at 1:55 PM, writer asked Patient #1 to review the agency medication list as compared to what Patient #1 is taking. RN B remained in the home to review. Patient #1 stated, “I am taking Metoprolol 100mg. It changed when my blood pressure was getting high awhile back. I am not taking Amlodipine. Haven’t been taking that for a few weeks.” Record review of Patient #1’s record 09/27/2023 – 11/05/2023 revealed Patient #1 had an RN visit 3 times per week for a total of 6 weeks, and there were no documented order update or reconciliation of changes in the agency medication profile for Metoprolol or Amlodipine. A home visit for Patient #3 was conducted at the patient’s residence on 11/06/2023 from 3:35 PM to 3:55 PM with PTA (Physical Therapist Assistant) D. PTA D did not remain in the home. Upon cessation of home visit at 3:55 PM, writer asked Patient #3 to review the agency medication list as compared to what Patient #3 is taking and observed Patient #3 take out a box of medications currently taking. Patient #3 removed a medication bottle that read “Potassium Chloride 10 meq (milliequivalent) take 1 tablet by mouth twice daily. Order date 10/02/2023.” Patient #3 stated, “Oh yeah, I take Potassium.” Patient #3 Daughter G stated, “[Patient #3] takes Potassium twice a day since beginning of October.” Writer reviewed the medication list and Patient #3 Daughter G confirmed Potassium was not on the medication list. When asked how often the nurse reviews medications, Patient #3 Daughter G replied, “[RN B] reviews medications weekly.” Record review of Patient #3’s “Home Health Certification and Plan of Care” medication orders dated 10/04/2023 – 12/02/2023 and review of “Medication Profile” (showing current medication orders and printed effective 11/07/2023) revealed Potassium Chloride was not listed as an active medication on this agency’s medication profile. During the timeframe of 10/04/2023 – 11/06/2023, an RN conducted a visit 1 time per week for a total of 5 weeks, and there were no documented order updates or reconciliation changes in the agency medication profile that Patient #3 had been taking Potassium Chloride. A home visit for Patient #4 was conducted at the ALF (Assisted Living Facility) where Patient #4 resides on 11/07/2023 from 9:00 AM to 9:45 AM with RN E. Writer did not observe RN E ask about Patient #4’s medications with ALF Staff F during this time. Upon cessation of home visit, RN E did not remain in the ALF. At 9:50 AM, writer asked ALF Staff F for the ALF’s MAR (Medication Administration Record) to compare the medication lists. Record review of the ALF MAR for month of November for Patient #4 revealed “Potassium Chloride 20 meq: Discontinued.” Record review of Patient #4’s “Home Health Certification and Plan of Care” medication orders dated 08/15/2023 – 10/13/2023 and 10/14/2023 – 12/12/2023, and review of “Medication Profile” (showing current medication orders and printed effective 11/07/2023) revealed “Potassium Chloride (Klor-Con 20) 1 tablet once daily by mouth” which did not match the medication profile for the ALF in which Patient #4 resides. During an interview with ALF Staff F on 11/07/2023 at 9:50 AM, when asked about Patient #4’s Potassium and if Patient #4 is taking this medication, ALF Staff F replied, “No, Patient #4 does not take Potassium. I don’t know when it was discontinued.” Record review of Patient #4’s RN visit documentation on 11/07/2023 under “Health Management” did not reveal any medication assessment or review completed (the agency’s software system has check boxes for ‘medication reconciled’, ‘new/changed medications in the home,’ ‘medication issues.’” During an interview with Administrator A on 11/07/2023 at 1:10 PM, when asked about the agency’s process and expectations for medication review and reconciliation, Administrator A replied, “On the first visit, we look at the bottles of medications and also compare their medication list to the facility list (if that is where they reside) and compare to referral information. On subsequent visits, we ask if there was a doctor appointment or any medication changes. They can add medications or change orders and send off for signed orders. If at a facility, they could talk to the facility nurse and review.” When asked if the agency had anything more specific regarding staff expectations for medication review to ensure patients and the agency have a most accurate list, Administrator A replied, “This is all we have. Nothing more specific.” Review of home visit findings were reviewed and confirmed with Administrator A on 11/07/2023 from 1:45 PM to 2:15 PM. During an interview with Administrator A on 11/07/2023 at 2:45 PM, in a follow up for Patient #4’s medication discrepancies, Administrator A stated, “Our Nurse Practitioner has Potassium on the list, but in looking at some communication notes, it shows the patient went to the cardiologist and Potassium was discontinued.” Record review for Patient #4’s Cardiology visit orders dated back on 08/15/2023 revealed, “Stop KCL (Potassium). Spoke with facility manager to discuss new orders.””