Every finding on record at Care IV Inc.

On 11/15/2021 at 12:10 PM, 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 11/18/2021 at 9:15 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) did not include all medications during the review of the patients medications in 2 (#6 and #10) 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. Findings follow: 1. A document titled, "Care IV Home Health -Fay PLAN OF CARE" (POC) for Patient #6, showed "Safety Measure for O2 Precautions Start Effective Date: 09/07/2021" Review of a document titled "Care IV Home Health - Fay OASIS Nurse Recertificaton" dated 11/05/2021, contained documentation of "Has O2 PRN at 2 lpm [liters per minute] if needed." Review of a document titled "Care IV Home Health - FAY Medication Profile" dated 11/08/2021 did not list O2 as a current medication Patient #6 was currently taking.. 2. A document titled, "Care IV Home Health -Fay PLAN OF CARE" (POC) for Patient #10, showed "Safety Measure for O2 Precautions Start Effective Date: 07/13/2021" Review of a document titled "Care IV Home Health - Fay OASIS Nurse Recertificaton" dated 09/09/2021, contained documentation of "Patient on continuous O2 at 2L" Review of a document titled "Care IV Home Health - FAY Medication Profile" dated 09/13/2021 did not list O2 as a current medication Patient #10 was currently taking.. 3. During an interview on 11/18/2021 at 8:30 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel # 2 confirmed the Agency staff did not include O2 during the medication review for Patient #6 and Patient #10 by stating "we will correct this."