Every finding on record at Heartfelt Home Healthcare Services, Inc.

Based on the findings of an onsite unannounced Medicare recertification, state licensure and focused infection control survey conducted 03/02/2021 through 03/05/2021, Heartfelt Home Healthcare Services, Inc. was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification, state licensure and focused infection control survey conducted 03/02/2021 through 03/05/2021, Heartfelt Home Healthcare Services, Inc. was found not to be in compliance with the following requirement(s) of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of clinical records (CR), agency policy and staff (EMP) interview it was determined the agency failed to maintain an accurate medication list per physician orders for one (1) seven (7) CR reviewed (CR3). Findings Included: Review of the agency policy and procedures was conducted on 3/05/2021 at approximately 9:00 a.m. which revealed, "Medication Set Up Policy... SPECIAL INSTRUCTIONS... 4. The nurse must always read the pharmacy labels carefully whether he/she is filling a medication box or administering the medication. The nurse should then compare the medication labels to the 485, checklist, and/or MAR before administering the medication or filling the medication box/dispenser." Review also revealed "Medication Administration... POLICY... SPECIAL INSTRUCTIONS... 7. Prior to the administration of any medication by any route, the nurse will verify: a. Medication is the correct by comparing physician order with medication label." Review of CR3 during a Home Visit on 3/03/2021 at approximately 10:00 a.m. revealed, "HOME HEALTH CERTIFICATION AND PLAN OF CARE" with a start of care date of 7/23/2020 and a current "certification period From: 1/19/2021 Thru: 3/19/2021... Orders for Discipline and Treatments... Weekly nursing visit to include: ...weekly medication box prefill management and monitoring... Medications... Atorvastatin 20 MG TABLET... 1 TABLET... BEDTIME... BY MOUTH... Start: 7/23/2020 Administered By: Self." A medication reconciliation was conducted as part of the home visit and revealed two (2) bottles of ATORVASTATIN 40mg - take 1 tablet by mouth daily at bedtime. Surveyor discussed the Prescription discrepancy with the Nurse performing the Skilled Visit (PF10). A call was made to the prescribing Physician to clarify the order. It was determined that the original Prescription was for "ATORVASTATIN 40mg - take 1 tablet by mouth daily at bedtime", and was written 1/03/2020. Further review revealed "HOME HEALTH CERTIFICATION AND PLAN OF CARE" for the following Certification Periods contained the incorrect Atorvastatin dosage of "20 MG TABLET... 1 TABLET... BEDTIME... BY MOUTH... Start: 7/23/2020 Administered By: Self." Certification Period From: 07/23/2020 Thru: 9/20/2020; Certification Period From: 09/21/2020 Thru: 11/19/2020; Certification Period From: 11/20/2020 Thru: 1/18/2021; and Certification Period From: 01/19/2021 Thru: 3/19/2021. In short, agency staff failed to discover this prescription error beginning with the start of care assessment on 7/23/2020, during the three (3) aforementioned recertifications, and all weekly skilled nursing visits for "medication box prefill management and monitoring" from 7/23/2020 through 3/03/2021. An interview with the Agency Administrator on 3/03/2021 at approximately 3:00 p.m. confirmed the above findings.