Every finding on record at Gideon Healthcare Group Inc

Purpose of visit: Recertification/Relicensure/Complaint Survey 10/13/2021 Census: L&C-62 LHHS-42 PAS-129 Investigation TX number: 275676, 269143, 261729, 266186 10/15/2021 A Recertification/Relicensure/Complaint Survey entrance conference was conducted on 10/13/2021 at 10:35 AM with the Administrator and Director of Nurses the agency was informed that the purpose of the survey was to conduct a Recertification/Relicensure/Complaint Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 10/15/2021 at 11:52 AM with the Administrator and Director of Nurses. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations.

Purpose of visit: Recertification/Relicensure/Complaint Survey 10/13/2021 Census: L&C-62 LHHS-42 PAS-129 Investigation TX number: 275676, 269143, 261729, 266186 10/15/2021 A Recertification/Relicensure/Complaint Survey entrance conference was conducted on 10/13/2021 at 10:35 AM with the Administrator and Director of Nurses the agency was informed that the purpose of the survey was to conduct a Recertification/Relicensure/Complaint Survey. The "Home and Community Support Services Agencies (HCSSAs), What To Expect During Your Agency's Survey" was provided and explained. The information card giving instructions on how to complete the on-line comment survey was provided. An exit conference was conducted on 10/15/2021 at 11:52 AM with the Administrator and Director of Nurses. The preliminary findings of the survey were discussed, and a written copy provided. The agency was informed which records were duplicated. The agency was afforded the opportunity to ask questions regarding the survey and given the opportunity to provide additional information. Additional information was not received. Written instructions were provided and explained for submitting a plan of correction within 10 days of receipt of the Statement of Violations.

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, record review and interview, the agency failed to maintain an accurate and current medication list in the client record in three (Patients #1, #2, and #3) of three patients whose medications were reviewed during a home visit. The failure placed Patients #1, #2, and #3 at risk of harm due to possible duplication of medication, adverse medication reactions and ineffective medication regimen. FINDINGS INCLUDED: PATIENT RECORD REVIEW: Active patient records reviewed on 10/13/2021. PATIENT #1: The record included a POC with a treatment period of 09/06/2021 to 11/04/2021 was dated 09/03/2021 and signed by staff RN (RN A). During a home visit with Patient #1 on 10/14/2021 at 10:00 a.m., the surveyor observed and reviewed Patient # 1's medications. Two discontinued medications were listed on the POC and medication profile, Cyanocobalamin Oral (Vitamin B12)100 mg every day, and Lidocaine pain relief roll-on 4% as needed had been discontinued by the patient. Patient #1's record did not include a current medication list on the "Medication profile" nor the POC. PATIENT #2: The record included a POC with a treatment period of 08/24/2021 to 10/22/2021 was dated 08/24/2021 and signed by staff RN (RN B). During a home visit with Patient #2 on 10/14/2021 at 10:25 a.m., the surveyor observed and reviewed Patient # 2's medications. A discontinued medication that was listed on the POC and medication profile, Fluticasone Propionate Nasal 50 MCG/ACT twice a day had been discontinued by the patient. Patient #2's record did not include a current medication list on the "Medication profile" nor the POC. PATIENT #3: The record included a POC with a treatment period of 08/25/2021 to 10/23/2021 was dated 08/24/2021 and signed by staff RN (RN B). During a home visit with Patient #3 on 10/14/2021 at 11:00 a.m., the surveyor observed and reviewed Patient # 3's medications. Patient #3's medications included the following medications in the patient’s home that were not listed in the patient record: 1. Turmeric Curcumin 500mg with ginger powder. 2. Magnesium Citrate 400 mg. 3. Potassium 550mg from Potassium gluconate 90mg. 4. Probiotic 100 million organism. 5. Airborne with Vitamin C and Zinc. 6. Visine with pheniramine Maleate .3%. 7. Vitamin C with Zinc and echinacea. 8. A&D Ointment. Discontinued medications by the patient that were listed on the POC and medication profile: Lamisil external 1%.Ibuprofen 200mg.Benadryl Allergy 25mgVitamin E 400 unit.Potassium 99mg.Eye Itch Relief 0.025%.Potassium 99mg.Patient #3's record did not include a current medication list on the "Medication profile" nor the POC. During an interview with the Administrator and Director of Nursing on 10/14/2020 at approximately 12:58 p.m. the surveyor discussed the above findings and asked why Patients #1, #2, and #3 patient records did not contain an accurate and current medication list/profile. The DON replied, "The nurses are supposed to update the medication profiles and are expected to check the medications every visit." Agency policy titled "MEDICATION LIST AND MONITORING PC.17" revised 080120 read in part: "PURPOSE To outline a process for ongoing medication monitoring. POLICY ...A medication profile/list will be maintained on all patients/clients. Medication monitoring will include appropriate data/information to develop an accurate patient/client medication history and a current, complete medication profile ...PROCEDURE 1. The agency will maintain a current, accurate list of all prescription and over-the-counter...medications taken by the patient/client ...Professional clinical staff will update the medication list with any change in the medication regimen."