Every finding on record at American Home Care Express Inc

An investigation was conducted on 05/10/24 for Complaint #242495/106251. The complaint was found to be substantiated with standard level citations. Abbreviations: IV = Intravenous RN = Registered Nurse SN = Skilled Nurse

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 the clinical record review and staff interview, it was determined the Agency staff failed to review and reconcile medications in 3 of 4 (Pts. #2, 3 and 4) records reviewed. Findings include: 1. Patient #2 was admitted to the Home Health Services on 01/15/24 with the Diagnoses of foreign body in anus and rectum, sequent encounter and Type 2 Diabetes Mellitus with Diabetic Neuropathy, with new medications. The clinical record was reviewed on 05/10/24. The SN failed to document the review/ reconciliation of the patient’s medication on 02/29/24. 2. Patient #3 was admitted to the Home Health Services on 01/15/24 with the diagnosis of Type 2 Diabetes Mellitus without Complications. The clinical record included a plan of care dated 01/17/24 that included, “…SN to perform medication review each skilled nursing visit and reconcile medications as indicated.” The SN visit notes on 02/08/24, 02/15/24 and 03/29/24 lacked documentation that medications were reviewed/reconciled by the SN. 3. Patient #4 was admitted to the Home Health Services on 03/15/24 with the Diagnoses of: Pressure Ulcer of Sacral Region Stage 2 and Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. The clinical record included a plan of care dated 03/15/24 that included, “…SN to perform medication review each skilled nursing visit and reconcile medications as indicated." The clinical record was reviewed on 05/10/24. The SN failed to document the review and reconciliation of the patient’s medication on 03/22/24. 4. The findings were confirmed during the interview with the Director of Clinical Services on 05/10/24 between 12:30 pm and 1:30 pm.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on the clinical record review and staff interview, it was determined the Agency staff failed to educate the patient/ caregiver on medications in 2 of 4 (Pts. #1 and 4) records reviewed. Findings include: 1. Patient #1 was admitted to the Home Health Services on 02/20/24 with the diagnosis of Type 2 Diabetes Mellitus with Other Specified Complications. The clinical record included a plan of care dated 02/20/24. The plan of care included six new medications, "...Z pack... Benzonatate... Hydrocodone... Vitamin B 12... Lisinopril... Eliquis..." The plan of care also documented, "...SN to instruct patient/caregiver on new and or changed medications..." The SN visit note dated 02/23/24 included education on the "Z pack". The note lacked documentation of education provided to the patient/caregiver of the remaining new medications. 2. Patient #4 was admitted to the Home Health Services on 03/15/24 with the diagnoses of Pressure Ulcer of Sacral Region Stage 2 and Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified. The clinical record was reviewed on 05/10/24. The clinical record included a plan of care dated 03/15/24 that included, “…SN to instruct on all new and changed medication and reinforce teaching related to use of medications…” The clinical record included an order to discontinue Furosemide on 03/19/24. The next SN visit was dated 03/22/24. The SN visit note lacked documentation on education given to the patient/caregiver regarding the discontinuation of Furosemide. 3. The findings were confirmed during the interview with the Director of Clinical Services on 05/10/24 between 12:30 pm and 1:30 pm.