Every finding on record at Gracon, Inc.

On 07/29/2024 at 10:00 AM, 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 42 CFR Part 484 Conditions of Participation for Home Health Agencies. On 08/01/2024 at 10:30 AM, an exit conference was conducted with Agency Representatives. Preliminary findings of the survey 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 record review and staff interview, it was determined the Agency failed to ensure a complete and accurate medication list with a documented complete review of all medication side effects and possible drug interactions in 2 (#2, #4) of 8 (#1-#8) records reviewed. This failed practice has the potential to negatively impact all patients on census as there was a potential for adverse reactions or interactions without a comprehensive review completed. During review of Clinical Record #2, on 07/24/2024, Skilled Nurse (SN) documented "Receiving Chemo(therapy) today on a document titled "Skilled Nursing Visit" On the next visit, the Skilled Nursing Visit document dated 07/29/2024, SN documented "Sulfa antibiotic added". Neither of these medications were evident on the current medication list. During an interview, Agency Personnel #1 was asked if either medication was added. Surveyor was informed "No. Neither of those have been added to the medication list." A review of Clinical Record #4 revealed documentation by the SN that "Tezspire" (an injected medication for severe asthma) was prescribed on 07/17/2024. This was not on the medication list provided to surveyor as the most current. Agency Personnel #1 was asked if the medication had been added to the patients medication profile. "No. It was not added."

On 11/02/2021 at 12:10 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 11/04/2021 at 10:45 AM, an exit conference was conducted with Agency Representatives. Preliminary findings of the survey 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 during the review of the patients medications in 1 (#2) of 5 (#1 - #5) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census receiving O2 therapy by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patients medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. Findings follow: 1. A document titled, "Home Health Care Certification and Plan of Care" (POC) dated 09/18/2021 to 11/14/2021 showed "DME [durable medical equipment] Oxygen." and safety measures for Patient #2 for "02 precautions." Review of a document titled "Visit Note Report dated 10/26/2021" showed the SN assessment and documentation of "O2 at 2 LPM [Liters Per Minute] via NC [Nasal Cannula]." Review of a document titled "Medication Profile" dated 09/16/2021 - 11/14/2021 did not list O2 on the medication list . 2. During an interview on 11/04/2021 at 9:35 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1 and #2 confirmed the Agency staff did not include 02 Patient #2 was currently using during a review of medications. Agency Personnel #2 stated "Oxygen was not on the medications list." .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: . Based on Clinical Record review and staff interviews, the Agency failed to ensure the established individualized Plan of Care (POC) was followed regarding Skilled Nurse (SN) assessment and interventions as ordered by the Physician in 2 (#1 and #2) of 5 (#1 - #5) Clinical Records reviewed. The deficient practice identified, if continued, could result in potential harm or risk of adverse outcomes or re-hospitalization for patients by delaying the SN and Physician's ongoing assessment of patient needs and progression toward goals. Findings follow: 1. Review of Clinical Record #1 for period 10/15/2021 to 12/12/2021 contained a form titled "Home Health Certification and Plan of Care" which included orders for the SN to report to Physician "Temperature greater than (>) 99.6 or less than () 150 or less than () 2 lbs or less than (<) 5 lbs." Review of a Documents titled "Skilled Nurse Visit" dated 10/01/2021 and 10/14/2021 revealed that on 10/01/2021 the SN documented "Weight is up 2 lbs this AM. On 10/14/2021 "weight is up 2 lbs. today from last visit". There was no evidence the Physician was notified of weight gain greater than 2 lbs. as ordered for 10/01/2021 or 10/14/2021 SN visits. 5. During an interview on 11/04/2021 at 9:35 AM, Agency Representatives were provided an opportunity to present additional documentation. With no additional documentation presented, Agency Personnel #1and #2 confirmed the SN failed to notify the physician of Patient # 1 and Patient #2 of vital signs being out of ordered parameters. .