Every finding on record at Chi National Home Care, LLC

On 1/30/2023 at 12:50 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 02/02/2023 at 3:00 PM, an exit conference was conducted with Agency Representatives. Preliminary findings 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 all medications for reconciliation and medication interaction checks in 3 (#5, #8, #10) of 10 (#1-#10) clinical records reviewed. This failed practice by the SN posed a risk of potential harm for all patients on census by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patient's medication regimen related to the potential adverse effects, significant side effects, or significant drug interactions. A review of Clinical Record #5 revealed a Document titled Client Medication Report lists "Acidophilus 6 Billion- 2 gummies daily, by mouth." When viewed on the Electronic Medical Record (EMR), the Acidophilous is highlighted in the color blue. Medications highlighted in blue are excluded from having the interactions checked against all other medications entered into the EMR or the computer charting system utilized by the Agency. A review of Clinical Record #8 revealed the following: 1. A document titled "Home Health Certification And Plan of Care" with dates of 1/26/2023 through 03/26/2023, lists "Oxygen Supplies" under DME (Durable Medical Equipment) and Supplies section. 2. Client Medication Report shows no Oxygen listed. When asked for clarification, Agency Staff #1 affirmed the patient was using oxygen. 3. When Agency Staff #1 was asked if oxygen was on the medication profile, the answer was "No. The nurse forgot to add that at Start of Care." A review of Clinical Record #10 revealed: A document titled "Client Medication Report" listing "SM Antacid 500 2mg 3 times daily by mouth" highlighted in the color blue. Medications highlighted in blue are excluded from having the interactions checked against all other medications entered into the EMR for the computer charting system utilized by the Agency. Agency Staff were given an opportunity to provide additional evidence. None was provided.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: During Clinical Record Review and Agency Staff interview, it was determined the patient's plan of care did not contain specific and individualized orders for patient/caregiver education and training. There was also a lack of specific interventions in 1 (#9) of 10 (#1-#10) Clinical Records reviewed. This failed practice by the Skilled Nurse (SN) had the potential to affect all patients on census in that a lack of an individualized plan of care may impede early interventions, treatments to prevent complications of illness, prolonging of illness and potential rehospitalizations. Review of Clinical Record #9 POC (Plan of Care) revealed a primary diagnosis of "hypertensive heart disease with heart failure" and an order for "PRN visit for the following reason: weight gain of 3 lbs. (pounds) in 1 day or 5 lbs. in one week." There was no evidence the agency monitored the patients weights or provided teaching concerning weight monitoring and its relation to CHF (Congestive Heart Failure) self management. Agency Staff were given an opportunity to provide additional evidence. None was provided.