Every finding on record at Grace Home Health Care, Inc

A Recertification Survey was conducted in conjunction with the evaluation of Emergency Preparedness requirements on 03/15/2024. Standard level deficiencies cited. Abbreviations: AM = morning PM = afternoon SOC = Start of care Pt / Pts = Patient / Patients

Name/contact information of clinical manager CFR(s): 484.60(e)(5) Name and contact information of the HHA clinical manager. This ELEMENT is not met as evidenced by: Based on a review of the Agency's Pt. admission folder, observation during home visits, clinical record review and staff interview, it was determined for 7 of 7 Pts. (Pts. #1 to 7), the Agency failed to provide information regarding the Agency Supervisor and their contact information. Findings include: 1. The Agency Pt. admission folder was reviewed on 3/13/24. The folder lacked information identifying the Agency Supervisor's name and contact information. 2. The following home visits were conducted on 3/12/24 at 3:00 PM to 3/13/24 from 10:00 AM to 2:00 PM: Pt. #1 SOC 2/14/24 Pt. #2 SOC 1/16/24 Pt. #3 SOC 10/23/23 During the home visits, the Pt. admission folders were reviewed. The folders lacked the name and contact information of the Agency Supervisor. 3. The clinical records of the following Pts. were reviewed from 3/12/24 through 3/14/24: Pt. #1 SOC 2/14/24 Pt. #2 SOC 1/16/24 Pt. #3 SOC 10/23/23 Pt. #4 SOC 6/13/23 Pt. #5 SOC 11/25/24 Pt. #6 SOC 7/12/23 Pt. #7 SOC 12/28/23 The clinical records reviewed lacked documentation the Pts. were notified of the Agency Supervisor's name and contact information. 4. During an interview with the Agency Supervisor on 3/14/24 at 11:55 AM, the Agency Supervisor indicated the same admission folder is given to all Pts. and confirmed the finding.

Recertification survey completed. Standard level deficiencies cited. A Focused Infection Control Survey (FIC) was conducted on 4/2/21. Grace Home Health Care, Inc was in compliance with the requirements for Infection Control for COVID-19. Abbreviations: # - Number Pt/Pts = Patient/Patients POC/ PsOC = plan of care/ plans of care MD - Medical Doctor SN - Skilled Nurse Intl = international Mg = Milligram PO = by mouth ML - milliliters AM - morning PM - afternoon/evening

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: . A. Based on home visits observations / interviews, clinical records review, Agency's policy review and staff interview, it was determined that the Agency failed to ensure that patients medication profiles were accurate and contain all medications that the patient is currently taking, this was found in 3 of 3 clinical records review with home visits. (Pts. # 2,3 and 1). Findings include: 1. Pt. #2 SOC 9/24/2020 Diagnoses: Chronic Systolic Congestive Heart Failure, Type 2 Diabetes Mellitus with Hyperglycemia and Old Myocardial Infarction. A home visit was conducted on 3/31/2021 at 3:30 PM with Employee #2 (SN) at Pt's #2 apartment. During the home visit interview and review of medications, the patient stated that MD "stopped the Lantus insulin months ago" the statement was confirmed by the visiting SN. The clinical record of Pt #2 was reviewed on 3/31/2021 at 11:00 AM and on 4/1/2021 at 10:00 AM. The record contained a Medication Profile for episode period of 3/23/2021 to 5/21/2021 that included as "Active Medications Lantus 100 units/ML subcutaneous solution 20 units bedtime subcutaneous". No modification physician orders were found in the record. 2. Pt. #3 SOC 2/10/2020 Diagnoses: Bilateral primary osteoarthritis of hip, Type 2 Diabetes Mellitus and Hyperlipidemia. A home visit was conducted on 3/31/2021 at 3:00 PM with Employee #2 (SN) at Pt's # 3 apartment. During the home visit interview and review of medications, the patient stated that on 3/2/2021 the "Doctor ordered to increase glipizide medication to 10 mg daily". The clinical record was reviewed and 3/31/2021 at 11:45 AM and on 4/1/2021 at 10:30 AM. The record contained a Medication profile for episode 2/4/2021 to 4/4/2021 that lacked glipizide medication on the "Active Medications" list. No modification physician orders were found in the record. 3. Pt. #1 SOC 1/11/2021 Diagnoses: Bilateral Primary Osteoarthritis of knee, Hypertensive Heart Disease without Heart failure. A home visit was conducted on 3/30/2021 at 2:45 PM with Agency Supervisor. During the home visit interview and review of medications, Pt.#1's daughter stated that Pt "has not been taking Vitamin D2 anymore and that instructions were to finish the supply and not take it anymore after." The clinical record was reviewed on 3/30/2021 at 1:30 PM and on 3/31/2021 at 9:00 AM. The clinical record contained a Medication profile for episode of 3/12/21 to 5/12/21. The Medication profile contained under Active Medications... "Vitamin D2 50,000 intl units (1.25 mg) oral capsule 1 capsule every Monday by mouth (PO) with start date 1/14/2021...." No modification physician orders were found in the record. 4. The Agency's policy titled "5.9 MEDICATION REVIEW" was reviewed on 4/1/2021 at 1:00 PM. The policy required...."Patient records must demonstrate that the drug regimen was reviewed, during the development of the initial comprehensive assessment, and that it occurs as an ongoing part of the care to the patient...A medication profile includes, but is not limited to: 1. All current medications....Medication Profile:...1.Ensure all patients/clients have a current list of all medications...a. The comprehensive assessment includes a review of all medications the patient is currently using, both prescription and non-prescription. 5. During interview with Administration and Agency Supervisor on 4/1/21 at 11:00 AM and 11:30 AM, the Agency Supervisor stated that the medications should be reviewed on every visit and updated on profile. The Agency Supervisor confirmed above findings.