Every finding on record at Care IV, Inc.

. On 10/03/2022 at 10:10 AM, an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare Recertification survey for compliance with the Conditions of Participation for Home Health. On 10/06/2022 at 10:20 AM an exit conference was conducted with Agency Representatives. Preliminary findings of the survey were discussed. .

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 and staff interviews, it was determined the Skilled Nurse (SN) failed to include Oxygen (O2) during the review of the patients medications in 2(#2and #9) of 10 (#1 - #10) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. Review of clinical record #2 revealed the following: A. Document titled, "Home Health Care Certification and Plan of Care" (POC) listed a diagnosis of "Dependence on supplemental oxygen (O2)". B. Document title "Medication Profile" showed no evidence that O2 was listed and checked for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 2. Review of clinical record #9 revealed the following: A. Document titled, "Home Health Care Certification and Plan of Care" (POC) listed a diagnosis of "Dependence on supplemental oxygen (O2)". B. Document title "Medication Profile" showed no evidence that O2 was listed and checked for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 3. During an interview on 10/06/2022 at 9:30 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 and #3 confirmed the Agency staff did not include Oxygen for patients #2 and #9 in the review of medications. Agency Personnel #3 stated "both these patients were seen by the same nurse and the O2 was not added to the medication profile."