Every finding on record at Alpine Home Health Care LLC

A recertification survey was completed on 2/3/22. One deficiency was cited.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure clinical records contained accurate documentation and information regarding clinical information for 1 of 2 current patients record reviewed, who had a diagnosis of diabetes (Patient #9). This deficiency was cited previously during a state licensure survey on 4/24/19. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include: AGENCY POLICY: According to the agency policy titled Initial and Comprehensive Assessments dated June 2021; "At the initial assessment and each subsequent assessment, prescription, over-the-counter drugs, and herbal preparations the patient is taking will be evaluated for possible adverse reactions, allergies, contraindication, and significant side effects." 1. The clinical record for Patient #9 was reviewed on 2/2/22. The plan of care for the certification period dated 12/12/21 through 2/9/22 revealed a start of care date of 10/13/21; diagnoses included hypertensive heart, heart failure, and type 2 diabetes mellitus with diabetic chronic kidney disease. Plan of care orders included skilled nurse (SN) visits once a week for three weeks and one visit every other week for education, hypertension management, and observe/assess genitourinary system; and physical therapy (PT) visits once a week for four weeks to provide gait training to improve ambulation. a) The agency failed to document accurate information in the client record, specifically the current medication list. Record review of Patient #9's medication list from the certification period 12/12/21 through 2/9/22 revealed the following medications; -duloxetine 30mg capsule delayed release orally one capsule daily -gabapentin 300mg capsule one capsule orally two times daily -glimepiride 4mg tablet one tablet orally one times daily -Insulin Lispro (U-100) 100 unit/ml given subcutaneous with meals per correction scale -Lantus Solostar (U-100) insulin 100 unit/ml 3ml given subcutaneously at bedtime -levothyroxine 112 mcg capsule 1 capsule orally one capsule daily -metformin 1000 mg tablet 1 tablet orally two times daily -pantoprzole 40 mg tablet, delayed release 1 tablet orally daily -polyethylene glycol 3350 17 gram oral powder packet, mix in eight oz of desired drink daily -simvastatin 40 mg tablet, 1 tablet orally at bedtime -tamsulosin .4mg capsule 1 capsule orally daily -tradjenta 5 mg tablet 1 tablet orally daily -ventolin HFA 90 mcg aerosol inhaler two puffs as needed every four hours Record review of Patient #9's clinical record revealed a verbal physician order dated 12/29/21, entered by licensed practical nurse (LPN #5), which was for the discontinuation of Insulin lispro and lantus solostar. Both medications were to be injected subcutaneously. The discontinuation date for the medication was listed as 10/13/21 which was the start of care date for Patient #9 with the agency. Review of the recertification assessment completed by registered nurse (RN #3) on 12/8/21, revealed Patient #9 no longer took any injectable medication. However, the plan of care developed based on the recertification assessment on 12/8/21 still listed both insulin lispro and lantus solostar as medications the patient was receiving. During interview on 2/2/22 at 4:01 p.m., LPN #5 stated during a SN visit on 12/29/21, Patient #9 told the LPN he was no longer taking the insulin lispro or the lantus solostar, which triggered the discontinuation of the verbal order for these medications. The LPN also stated, Patient #9 had not been taking the medications for a couple of months at least, which is why the LPN recorded the discontinuation date as 10/13/21. When asked if a medication reconciliation was completed, the LPN was unable to answer stating that it would be the responsibility of the nurse case manager. During interview on 2/3/21 at 11:42 a.m., the alternate administrator/clinical manager could not explain what had happened and RN #3 was unavailable for further interview because she was on leave. The alternate manager stated that a medication reconciliation should have been done, and agreed that the recertification assessment on 12/8/21, was contradictory to the information on the plan of care based on this assessment.