Every finding on record at E Medical Group of Texas No 1 LLC

No deficiencies cited.

Purpose of visit: Recertification survey Entrance date: 11/01/21 Census: Parent L&C – 56 LHH – 18

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, interview, and record review, the agency failed to have a current and accurate medication list in each patient record for 1 of 7 (#3) patient records reviewed. This failure could place all patients at risk for duplicate drug therapy, adverse drug interactions, and ineffective drug therapy due to an incomplete list of all medications being taken by the patient. This failure could prevent the physician from making changes to medications as needed. Review of a POC (Plan of Care), dated 09/18/21, indicated the patient had a start of care (SOC) date of 09/18/21 and a medication list to include the following medications: 1.) Amlodipine (used to treat high blood pressure) 5mg by mouth daily. 2.) Benzonatate (prescribed for cough) 100 mg by mouth every 8 hours as needed. 3.) Dexamethasone (Steroid- prescribed for shortness of breath) 4mg by mouth daily. 4.) Dulera (prescribed for shortness of breath (SOB) and wheezing) 2 puffs every morning and 2 puffs every evening. 5.) Montelukast (for Prophylactic wheezing/SOB) 10 mg by mouth daily. 6.) Oxygen (for shortness of breath) 1 Liter as needed. Review of an agency form titled, "Client Medication Report," dated 11/04/21, indicated Employee G, LVN (Licensed Vocational Nurse), reviewed the medication list on 10/26/21. There was no indication the medication list was reviewed after 09/19/21 and there was no indication the medication list was updated since the date of admission on 09/18/21. The medication list contained the same medications contained on the plan of care, dated 09/18/21. Review of nurse visit notes conducted by Employee G, LVN, dated 10/05/21 and 10/26/21, indicated the employee visited the patient on those dates and documented in the visit note portion..."Medications: Has the patient had any medication changes (New/Changed/Discontinued) since the last visit? None Identified." The notes indicated the patient was last seen by the physician on 10/04/21. During a telephone interview with Employee G, LVN (Licensed Vocational Nurse), conducted on 11/04/21 at 10:31 a.m. regarding medication reconciliation for Patient #3, when asked if she reviewed all medications the patient was taking during visits conducted on 10/05/21 and 10/26/21, she said she tries to review medications but not all the time. She said she knew the patient was prescribed Furosemide (a medication prescribed for fluid removal), but the patient said she was informed, by the physician, she only had to take the medication as needed for swelling (edema). When asked why she didn’t update the medication profile, she said she didn’t know. She thought she had. She said she must have forgotten. When asked about the medication Amlodipine (prescribed to help control blood pressure) and why it was not updated, she said she wasn’t sure. Review of a nurse visit note conducted by Employee F, RN (Registered Nurse), dated 10/14/21, indicated documentation in the assessment portion..."Medications: Has the patient had any medication changes (New/Changed/Discontinued) since the last visit? None Identified." The note indicated the patient was last seen by the physician on 10/04/21. During a telephone interview with Employee F, RN, conducted on 11/04/21 at 9:52 a.m. regarding Patient #3, when asked if she reviewed the patient’s medications during a visit conducted on 10/14/21, she said yes. When asked why she didn’t document the medication changes on the visit note and why she didn’t update the medication list, she said she must have forgotten. When asked if she was aware the patient was prescribed Furosemide (a diuretic – used to help reduce fluid retention), she said no. She said, when she asked to review the medications on 10/14/21, the daughter only provided a few medications and said the patient was taking the medications as instructed by the physician. When asked if the patient was taking Amlodipine (a medication used to treat high blood pressure), she said yes. Just not as prescribed. She said the physician instructed the patient to take the medication only when her blood pressure was high. When asked if she reviews patient medications at every visit, she said yes. Review of a nurse visit note conducted by Employee E, RN, dated 10/20/21, indicated documentation in the assessment portion..."Medications: Has the patient had any medication changes (New/Changed/Discontinued) since the last visit? None Identified." The note indicated the patient was last seen by the physician on 10/04/21. During a telephone interview with Employee E, RN, conducted on 11/04/21 at 9:25 a.m. regarding Patient #3, when asked if she reviews patients’ medications every visit, she said yes. When asked about the medication Furosemide, she said she was not aware the patient was prescribed the medication and said the patient must not have provided the medication bottle when she was reviewing her medications. She said she would not have known about the medication unless the patient had provided the medication bottle during the review. She said the patient did not provide additional information regarding her medications and how they were being taken. She did not identify any changes that would require an updated medication list. When asked about the medication Amlodipine, she said the patient did not provide any information about the medication when asked. During a home visit and interview with Patient #3, conducted on 11/03/21 at 2:00 p.m., when asked if the nurse reviews all her medications during each visit, she said no. When asked how long she had been taking Furosemide 40mg by mouth daily, she said she picked up the medication following a physician appointment on 10/04/21. When asked if she was taking the medication as written on the prescription bottle, she said no. She said she stopped taking the medication every day because the medication made her go to the bathroom a lot. When asked if she informed the physician about how the medication made her feel, she said yes. When asked about the medication Amlodipine (a medication used to treat high blood pressure) and if she was taking it as prescribed, she said no. She said the medication made her blood pressure drop too low and it made her feel tired and weak. She said she was instructed, by the physician, not to take the medication on days when her blood pressure was low. She said the medication change was made during a physician office visit on 10/04/21. During an interview with the administrator, conducted on 11/04/21 at 9:20 a.m. regarding client medication reconciliation, when asked how often nurses are required to reconcile patient medications, she said every visit. She said the nurses are required to check the patient’s medications for any changes every visit and update the medication list as appropriate. Review of an agency policy titled "Medication Profile/Drug Regimen Review." dated 07/01/18, indicated, "Ongoing patient medication monitoring is a collaborative process to identify actual or potential medication-related problems and determine the effectiveness of the current medication regimen. A current medication profile will be initiated , updated, and maintained according to state/federal regulations, managed care contracts, and/or as the patient's medications change...The Medication Profile must be current and is updated as changes occur with the patient's medication regimen."

Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This ELEMENT is not met as evidenced by: Based on interview and record review, the registered nurse failed to update and revise the comprehensive assessment within the last 5 days of every 60-day period for 1 of 7 (#6) patient records reviewed. This failure could negatively impact patient outcomes due to a lack of a nursing assessment and prevents the physician from prescribing new orders for patient care if needed. Review of a Plan of Care (POC), dated 10/07/2020, indicated the patient had a start of care (SOC) date of 09/10/2020 and a certification period of 09/10/2020 to 11/08/2020. Review of the nurse visit notes for the time-period of 11/01/2020 to 11/08/2020, did not indicate a nurse visit was conducted during this time and there was no indication a comprehensive reassessment was completed, by the nurse, for an additional certification period. Review of an agency form titled "Client Coordination Note Report," dated 11/08/2020, indicated the visit for 11/07/2020 was declined by the patient. Review of the nurse visit notes, indicated the recertification assessment was completed on 11/10/2020. Two days after the required time-period for completing the recertification assessment. During an interview with Employee A, RN (registered nurse)/administrator, conducted on 11/03/21 at 3:50 p.m. regarding a recertification assessment on Patient #6, when asked why the assessment was not conducted within the last 5-day window of the certification period, she said the patient refused the visit because the patient had a lot of things to do and didn’t have time to be seen. She said the patient said she had appointments to keep and errands to run and requested the visit be conducted the following week. When asked if she informed the patient that the nurse only had a specific amount of time to complete the recertification assessment and needed to complete the assessment by 11/08/2020, she said no. The employee said she didn’t think to tell the patient that and said the patient didn’t like to be seen on weekends. Review of an agency policy titled "Patient Assessment/Reassessment," revised December 2019, indicated, "The comprehensive assessment including the OASIS items must be updated at the following points of time: The last five (5) days of every 60 days beginning with the start of care date. The follow-up assessment is conducted by the appropriate clinician to identify the patient's current health status and continued need(s) for home health services."

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 interview and record review, the administrator failed to be responsible for all day-to-day operations of the home health agency in that the administrator failed to organize and direct the agency's ongoing functions to ensure implementation of agency policies and procedures and provision of quality care to agency patients for 2 of 7 (Patient #3 and Patient #6) patients reviewed in that: The administrator failed to ensure each patient received an appropriate assessment and reassessment by the appropriate discipline in order to meet the patient's needs for Patient #6 in accordance with agency policy and procedure and current standards of practice; and The administrator failed to ensure a complete and accurate medication list was updated and complete, to include all medications the patient was taking for Patient #3 in accordance with agency policy and procedure and current standards of practice. These failures could result in harm to patients and dissatisfaction with home health services. Failure to ensure services are provided according to current standards of practice could result in the physician being unable to make changes in patient care and treatment as needed. Patient #3: Review of a POC (Plan of Care), dated 09/18/21, indicated the patient had a start of care (SOC) date of 09/18/21 and a medication list to include the following medications: 1.) Amlodipine (used to treat high blood pressure) 5mg by mouth daily. 2.) Benzonatate (prescribed for cough) 100 mg by mouth every 8 hours as needed. 3.) Dexamethasone (Steroid- prescribed for shortness of breath) 4mg by mouth daily. 4.) Dulera (prescribed for shortness of breath (SOB) and wheezing) 2 puffs every morning and 2 puffs every evening. 5.) Montelukast (for Prophylactic wheezing/SOB) 10 mg by mouth daily. 6.) Oxygen (for shortness of breath) 1 Liter as needed. Review of an agency form titled, "Client Medication Report," dated 11/04/21, indicated Employee G, LVN (Licensed Vocational Nurse), reviewed the medication list on 10/26/21. There was no indication the medication list was reviewed after 09/19/21 and there was no indication the medication list was updated since the date of admission on 09/18/21. The medication list contained the same medications contained on the plan of care, dated 09/18/21. Review of nurse visit notes conducted by Employee G, LVN, dated 10/05/21 and 10/26/21, indicated the employee visited the patient on those dates and documented in the visit note portion..."Medications: Has the patient had any medication changes (New/Changed/Discontinued) since the last visit? None Identified." The notes indicated the patient was last seen by the physician on 10/04/21. During a telephone interview with Employee G, LVN (Licensed Vocational Nurse), conducted on 11/04/21 at 10:31 a.m. regarding medication reconciliation for Patient #3, when asked if she reviewed all medications the patient was taking during visits conducted on 10/05/21 and 10/26/21, she said she tries to review medications but not all the time. She said she knew the patient was prescribed Furosemide (a medication prescribed for fluid removal), but the patient said she was informed, by the physician, she only had to take the medication as needed for swelling (edema). When asked why she didn’t update the medication profile, she said she didn’t know. She thought she had. She said she must have forgotten. When asked about the medication Amlodipine (prescribed to help control blood pressure) and why it was not updated, she said she wasn’t sure. Review of a nurse visit note conducted by Employee F, RN (Registered Nurse), dated 10/14/21, indicated documentation in the assessment portion..."Medications: Has the patient had any medication changes (New/Changed/Discontinued) since the last visit? None Identified." The note indicated the patient was last seen by the physician on 10/04/21. During a telephone interview with Employee F, RN, conducted on 11/04/21 at 9:52 a.m. regarding Patient #3, when asked if she reviewed the patient’s medications during a visit conducted on 10/14/21, she said yes. When asked why she didn’t document the medication changes on the visit note and why she didn’t update the medication list, she said she must have forgotten. When asked if she was aware the patient was prescribed Furosemide (a diuretic – used to help reduce fluid retention), she said no. She said, when she asked to review the medications on 10/14/21, the daughter only provided a few medications and said the patient was taking the medications as instructed by the physician. When asked if the patient was taking Amlodipine (a medication used to treat high blood pressure), she said yes. Just not as prescribed. She said the physician instructed the patient to take the medication only when her blood pressure was high. When asked if she reviews patient medications at every visit, she said yes. Review of a nurse visit note conducted by Employee E, RN, dated 10/20/21, indicated documentation in the assessment portion..."Medications: Has the patient had any medication changes (New/Changed/Discontinued) since the last visit? None Identified." The note indicated the patient was last seen by the physician on 10/04/21. During a telephone interview with Employee E, RN, conducted on 11/04/21 at 9:25 a.m. regarding Patient #3, when asked if she reviews patients’ medications every visit, she said yes. When asked about the medication Furosemide, she said she was not aware the patient was prescribed the medication and said the patient must not have provided the medication bottle when she was reviewing her medications. She said she would not have known about the medication unless the patient had provided the medication bottle during the review. She said the patient did not provide additional information regarding her medications and how they were being taken. She did not identify any changes that would require an updated medication list. When asked about the medication Amlodipine, she said the patient did not provide any information about the medication when asked. During a home visit and interview with Patient #3, conducted on 11/03/21 at 2:00 p.m., when asked if the nurse reviews all her medications during each visit, she said no. When asked how long she had been taking Furosemide 40mg by mouth daily, she said she picked up the medication following a physician appointment on 10/04/21. When asked if she was taking the medication as written on the prescription bottle, she said no. She said she stopped taking the medication every day because the medication made her go to the bathroom a lot. When asked if she informed the physician about how the medication made her feel, she said yes. When asked about the medication Amlodipine (a medication used to treat high blood pressure) and if she was taking it as prescribed, she said no. She said the medication made her blood pressure drop too low and it made her feel tired and weak. She said she was instructed, by the physician, not to take the medication on days when her blood pressure was low. She said the medication change was made during a physician office visit on 10/04/21. During an interview with the administrator, conducted on 11/04/21 at 9:20 a.m. regarding client medication reconciliation, when asked how often nurses are required to reconcile client medications, she said every visit. She said the nurses are required to check the client’s medications for any changes every visit and update the medication list as appropriate. When asked if she was aware that medications were not always being reviewed by nursing professionals, she said no. Deficient medication reconciliation had not been identified prior to this survey. Review of an agency policy titled "Medication Profile/Drug Regimen Review." dated 07/01/18, indicated, "Ongoing patient medication monitoring is a collaborative process to identify actual or potential medication-related problems and determine the effectiveness of the current medication regimen. A current medication profile will be initiated , updated, and maintained according to state/federal regulations, managed care contracts, and/or as the patient's medications change...The Medication Profile must be current and is updated as changes occur with the patient's medication regimen." Patient #6: Review of a Plan of Care (POC), dated 10/07/2020, indicated the patient had a start of care (SOC) date of 09/10/2020 and a certification period of 09/10/2020 to 11/08/2020. Review of the nurse visit notes for the time-period of 11/01/2020 to 11/08/2020, did not indicate a nurse visit was conducted during this time and there was no indication a comprehensive reassessment was completed, by the nurse, for an additional certification period. Review of an agency form titled "Client Coordination Note Report," dated 11/08/2020, indicated the visit for 11/07/2020 was declined by the patient. Review of the nurse visit notes, indicated the recertification assessment was completed on 11/10/2020. Two days after the required time-period for completing the recertification assessment. During an interview with Employee A, RN (registered nurse)/administrator, conducted on 11/03/21 at 3:50 p.m. regarding a recertification assessment on Patient #6, when asked why the assessment was not conducted within the last 5-day window of the certification period, she said the patient refused the visit because the patient had a lot of things to do and didn’t have time to be seen. She said the patient said she had appointments to keep and errands to run and requested the visit be conducted the following week. When asked if she informed the patient that the nurse only had a specific amount of time to complete the recertification assessment and needed to complete the assessment by 11/08/2020, she said no. The employee said she didn’t think to tell the patient that and said the patient didn’t like to be seen on weekends. She said she was a new administrator and did not know what to do regarding the situation. She said she talked to the corporate office about the situation and was informed that a recertification assessment could still be completed. Review of an agency policy titled "Patient Assessment/Reassessment," revised December 2019, indicated, "The comprehensive assessment including the OASIS items must be updated at the following points of time: The last five (5) days of every 60 days beginning with the start of care date. The follow-up assessment is conducted by the appropriate clinician to identify the patient's current health status and continued need(s) for home health services." Review of an agency policy titled "Responsibilities of the Administrator," dated 09/27/18, indicated, "The Agency Administrator will assume overall responsibility and authority for the day to day operations of the Agency, including administrative and leadership functions, supervision of the established organizational plan and responsibility for ongoing communication with the Governing Body and the entire Agency staff...All personnel providing services to a patient will maintain communication to ensure their efforts effectively complement one another and support the goals and objectives outlined in the patient's plan of care."