Every finding on record at Athena Home Health LLC

Unannounced visits were concluded at Athena Home Health and Hospice on 1/13/2022 for the purpose of reviewing the Emergency Preparedness Code of Federal Regulations at §484.102, Condition of Participation for Home Health Agencies (HHA). The agency was in compliance with the requirements at the time of the survey.

Unannounced visits concluded at Athena Home Health and Hospice on 1/13/2022 for the purpose of recertification and re-licensure. Standard level deficiencies were identified.

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on clinical record review and interview with the agency personnel, for one of one patient (Patient #5) who required medication management, the agency nurses failed to document the medication pre-pour of controlled substances in accordance with the agency expectations. The findings include: Patient #5 had a start of care date of 12/31/19 and diagnoses that included vitamin B12 deficiency, congestive heart failure, polyneuropathy and anemia. The physician's orders for the certification period of 12/20/21 through 2/17/22 included nursing services one time a week for weekly pre-pouring medication and general assessments. Physician’s orders dated 12/20/21 directed to pre-pour Clonazepam 1.5 milligrams/mg by mouth daily for anxiety (a Scheduled IV Controlled substance) and Lyrica 150 mg, one tablet by mouth twice daily for neuropathic pain (a Scheduled V Controlled substance). Interview and review of RN #1’s nursing notes dated 12/23/21, 12/28/21 and 1/05/22 with the Administrator on 1/13/22 at 11 AM identified the weekly pre-pouring of Clonazepam 1.5 milligrams and Lyrica 150 mg but failed to identify nursing documentation of the starting amount of Clonazepam and Lyrica tablets found in the bottle in the home and a remaining balance after the nurse accessed the controlled substances, and failed to ensure the safety and accuracy of controlled substances belonging to the patient and accessed by the nurse to identify misuse or discrepancies. There was no policy to review for the pre-pouring of Controlled substances, although the Administrator indicated that the expectation is for the licensed staff to utilize the Controlled Substance Count Sheet.

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on review of the clinical records and interview with agency personnel, for one of one patient (Patient #5) who required medication management, the agency Administrator failed to ensure the development of appropriate policies and procedures for the management of controlled drugs to prevent misuse or discrepancies. The finding includes: Patient #5 had a start of care date of 12/31/19 and diagnoses that included vitamin B12 deficiency, congestive heart failure, polyneuropathy and anemia. The physician's orders for the certification period of 12/20/21 through 2/17/22 included nursing services one time a week for weekly pre-pouring medication and general assessments. Physician’s orders dated 12/20/21 directed to pre-pour Clonazepam 1.5 milligrams/mg by mouth daily for anxiety (a Scheduled IV Controlled substance) and Lyrica 150 mg, one tablet by mouth twice daily for neuropathic pain (a Scheduled V Controlled substance) Interview and review of RN #1’s nursing notes dated 12/23/21, 12/28/21 and 1/05/22 with the Administrator on 1/13/22 at 11 AM identified the weekly pre-pouring of Clonazepam 1.5 milligrams and Lyrica 150 mg but failed to identify nursing documentation of the starting amount of Clonazepam and Lyrica tablets found in the bottle in the home and a remaining balance after the nurse accessed the controlled substances, and failed to ensure the safety and accuracy of controlled substances belonging to the patient and accessed by the nurse to identify misuse or discrepancies. Interview and review of the agency policies with the Administrator on 1/13/22 identified agency staff will document all controlled medications in the clinical record and failed to identify policies and procedures to address the management of controlled drugs at any time in the patient's home.