Every finding on record at Caretenders Vs of Ohio, LLC

SUBSTANTIAL ALLEGATION SURVEY SUBSTANTIAL ALLEGATION OH00121730 COVID 19 FOCUSED INFECTION CONTROL SURVEY The following deficiency is based upon substantial allegation OH00121730 completed on 05/05/21. Caretenders VNA is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C, Home Health Agencies. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 482.42 related to Infection Control and 42 CFR Part 482.15(b)(6) related to Emergency Preparedness.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review, interview and policy review, the facility failed to ensure an initial assessment visit was completed within 48 hours of the patient's referral date or return home. This affected one (Patient #1) of three medical records reviewed. The agency census was 367. Findings include: Review of the medical record for Patient #1 revealed the patient was admitted to the agency on 04/14/21 with the primary diagnosis of pressure ulcer of sacral region stage IV. Review of the patient's medical record revealed the facility received a patient referral on 04/09/21 and the patient was discharged from a rehabilitation facility on 04/11/12. Review of the Oasis Admission Assessment, dated 04/14/21, revealed the assessment was not completed within 48 hours after the patient's referral date or returned home. Review of the medical record revealed no documented evidence of a physician's order to begin services greater than 48 hours after referral or discharge from the facility. Interview with Staff A on 05/04/21 at 12:43 PM confirmed the above findings. Review of the agency policy titled "Patient Assessment, Initial and Reassessment", revised 10/01/18, revealed all patients admitted to the agency will receive an initial assessment (eligibility determination and patient consent) by a staff Registered Nurse, Speech Therapist or Physical Therapist. OASIS comprehensive assessments are completed at patient admission on all adult patients. A qualified clinician performs a comprehensive assessment or reassessment visit in the following situations admission visit within 48 hours from referral or physician ordered start of care date. This deficiency substantiates Substantial Allegation OH00121730.

Emergency Preparedness Survey At the time of the emergency preparedness survey completed on 02/04/21, Caretenders VNA is in compliance with the provisions of 42 CFR Part 484.102, Conditions of Participation for Home Health Agencies.

Partial Extended Recertification Survey COVID 19 Focused Infection Control Survey The following deficiency is based on the partial extended recertification survey completed 02/04/21. Caretenders VNA 367137, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. A COVID 19 Focused Infection Control Survey conducted concurrently revealed the facility is in compliance with the requirements at 42 CFR Part 484.70 related to Infection Control.

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 observation, medical record review and staff and patient interview, the agency failed to ensure a review of all medications was conducted for three of 18 medical records reviewed (Patient #4, #6, and #7). The agency census was 374. Findings include: Review of the policy and procedure titled, Monitoring Medications, revised 05/01/19, revealed a drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. 1. Review of Patient #6's medication list during a home visit on 02/02/21 revealed the patient was ordered perphenazine-amitriptyline (antidepressant) 2 milligrams (mg) - 10 mg one tablet at bedtime. Observation of the prescription bottle revealed the patient was to take one to two tablets at bedtime. The medication list also failed to show the patient was taking a multivitamin once a day, fish oil 1000mg three times a day, Vitamin D 1.25 mg once a week, and Tramadol (treatment for pain) 50mg two tablets three times a day which were observed in the home. Interview with the patient at the time of the medication review confirmed the patient was taking the above listed medications. The patient also stated that she sometimes took two perphenazine-amitriptyline tablets. Interview with Staff E on 02/02/21 at 2:00 PM confirmed the above findings. 2. On 02/02/21 at 9:50 A.M. a review of the medications available for patient use in the home was completed during a home visit for Patient #4. The medication review revealed Lasix 20 milligrams (mg) was available and the medication label had instructions listed for the patient to take the medication every day. An interview with Patient #4 at the time of the home visit confirmed that the patient did take the Lasix as instructed on the medication bottle. Review of the physician ordered plan of care and the Medicine List revealed there was no order for Lasix. Further review revealed Exforge (for high blood pressure) 10/320 mg was available in the home. However, it was not listed as a current medication on the physician ordered plan of care, but it was listed as a current medication on the Medicine List. An interview with Staff A during the medication review confirmed the findings. 3. On 02/03/21 at 9:40 A.M. a review of the medications available for patient use in the home was completed during a home visit for Patient #7. The medication review revealed Klonopin 1 milligram (mg) tablets available to the patient and the prescription label instructed the patient to take 1mg as needed at bedtime. There was no order for Klonopin on the physician ordered plan of care, but it was included on the Medicine List. Further observation revealed over the counter (OTC) Gas Relief medication was in the patient's home. An interview with Patient #7 confirmed he/she had used the medication for several weeks. Review of the physician ordered plan of care and the Medicine List revealed no order for the medication. Review of the physician ordered plan of care revealed an order for BREO (steroid inhaler) 100 micrograms (mcg), but the medication was not available in the patient's home. An interview with the patient revealed he/she had not been taking the medication "for awhile now" because it was too expensive. Further observation revealed Azelastine (antihistamine) 0.1% nasal spray in the patient's home. An interview with the patient revealed he/she had used the Azelastine 0.1% for at least six months. The medication was not listed on the physican ordered plan of care or the Medicine List. An order for Levothyroxine (medication for hypothyroidism) 25 mcg by mouth was included on the physician ordered plan of care and on the Medicine List, but there was no Levothyroxine in the patient's home. An interview with the patient revealed he/she "ran out" of the Levothyroxine and he/she did not remember how long he/she had been out of the medication. An interview with Staff A during the home medication review confirmed the findings.