Every finding on record at Integracare Home Health Services, Inc.

Purpose of visit: recertification. Entrance date: 06/24/2024 Census: Licensed and Certified: 100

Purpose of visit: recertification. Entrance date: 06/24/2024 Census: Licensed and Certified: 100 Abbreviation List: RN - Registered Nurse LVN - Licensed Vocational Nurse mg - milligrams POC - Plan of Care SOC - Start of Care SN - Skilled Nurse GM - Gram

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 include a review of all medications the patient is currently using in order to identify potential side effects, drug interactions, side effects, duplicate and noncompliance with drug therapy for two of 5 patients (#5 and #2) observed for home visits in that: 1. RN A did not conduct a medication reconciliation of Patient #5's current medications. 2. LVN B did not accurately conduct a medication reconciliation of Patient #2's current medications. This failure could affect all patients in the agency and could result in medication error. The findings were: 1. Record review of Patient #5's POC (certification date of 06/08/2024 to 08/06/2024) revealed a SOC date of 06/08/2024, diagnosis included Unspecified Fracture of Lower End of Left Humerus (upper arm bone). Further review of this POC revealed orders and treatments included for SN to review medication profile/reconcile medications, instruct/reinforce medication management, and new medications Carvedilol (heart medication), Finasteride (medication to treat enlarged prostate), Mirabegron (used to treat urinary urgency), Omeprazole (decreases amount of acid in the stomach), Sucralfate (used to treat duodenal ulcers), and Tamsulosin (used to treat symptoms of enlarged prostate gland).." Record review of Patient #5's current medication profile listed Amlodipine (medicine for blood pressure), Carvedilol 3.125 tablet, Myrbetriq (Mirabegron) 25 mg tablet, Omeprazole 20 mg, Sucralfate 1 gm, and Tamulosin 0.4 mg, Amlodipine 10 mg, Simvastatin 40 mg, and Sucralfate 1 gm. During a home visit observation on 06/25/2024 at 09:45 a.m., Patient #5's current medications were reconciled with the agency's current medication profile. Interview with Patient #5 at this time revealed he was only taking Amlodipine (used for blood pressure), Simvastatin (used for high cholesterol), and Sucralfate. Patient #5 further revealed when he was discharged from the nursing home, all his other medications should have been discontinued as they were unnecessary. Patient #5 also revealed he had never had a discussion about his medications with the visiting nurses. During observation on 06/25/2024 at10:24 a.m., RN A was observed providing care for Patient #5. During the home visit, RN A did not reconcile Patient #5's current medications with the agency's medication profile. During interview on 06/27/2024 at 09:08 a.m., RN A revealed she received training on medication reconciliating upon hire. Further interview with RN A revealed she should go over each medication bottle with the patient with each visit, but was anxious. 2. Record review of Patient #2's POC (05/04/2024 to 07/02/2024) revealed a SOC of 01/05/2024, diagnosis included Pressure Ulcer of Right Heel, Traumatic Subdural Hematoma, and Unspecified Hearing Loss. During a home visit observation on 06/25/2024 at 01:29 p.m., LVN B was observed providing care for Patient #2. Further observation revealed LVN B reviewed Patient #2's medications by reading off of LVN B's medication list (on an electronic tablet) to Patient #2's family member. Patient #2's family member acknowledged the medications by LVN B. During interview on 06/27/2024 at 10:17 a.m., LVN B revealed medication reconciliation should be conducted every visit. LVN B Further confirmed she reviewed Patient #2's medications with the family member and did not review the medication bottles because the family member was aware of the medications. During interview on 06/26/2024 at 12:25 p.m., the Administrator revealed with each visit, staff are supposed to review medications in the home and medication list with the patient or caregiver to confirm what the patient was taking. Further interview revealed if medication reconciliation was not done, the patient could be taking the wrong medication or medications would not get refilled if they ran out. During interview on 06/26/2024 at 02:08 p.m., the Alternate Adminstrator revealed staff are supposed to bring out all the medications the patient was currently taking, check discontinued medications with what the patient had in the home, and contact the physician if any discrepancies, and reconcile each skilled nursing visit. Record review of the agency's policy and procedure titled "Medication Review and Documentation (10/2022)", read in part, "...The home health agency will assess all medications the patient is taking-both prescription and over-the-counter - to include all routes of medications during each patient visit...examine medication bottles, prescriptions, and current lists provided by the patient..."

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 observation, interview, and record review the agency failed to ensure two of 13 patients (#5 and #8) received home services that are written in an individualized POC in that: 1. RN A did not conduct a medication reconciliation for Patient #5 as written on the POC. 2. Patient #8 did not have a weekly SN visit according to the POC. This failure could affect all patients in the agency who received home health services and could result in treatment goals not met. The findings were: 1. Record review of Patient #1's POC (certification date 6/8/2024 to 08/06/2024) revealed a SOC of 06/08/2024, diagnosis included Unspecified Fracture of Lower End of Left Humerus (upper arm bone). Further review of this POC revealed orders and treatments included for SN to "review medication profile/reconcile medications, instruct/reinforce medication management, and new medications …" During a home visit observation on 06/25/2024 at 09:45 a.m., Patient #5's current medications were reconciled with the agency's current medication profile. Interview with Patient #5 at this time revealed he was only taking Amlodipine (used for blood pressure), Simvastatin (used for high cholesterol), and Sucralfate (used to prevent duodenal ulcers). Patient #5 further revealed when was discharged from the nursing home, all his other medications should have been discontinued as they were unnecessary. Patient #5 also revealed he had never had a discussion about his medications with the visiting nurses. During observation on 06/25/2024 at10:24 a.m., RN A was observed providing care for Patient #5. During the home visit, RN A did not reconcile Patient #5's current medications with the agency's current medication profile. During interview on 06/27/2024 at 09:08 a.m., RN A revealed she received training on medication reconciliating upon hire. Further interview with RN A revealed she should go over each medication bottle with the patient with each visit, but did not because she was anxious. During interview on 06/26/2024 at 12:25 p.m., the Administrator revealed with each visit, staff are supposed to review medications in the home and medication list with the patient or caregiver to confirm what the patient was taking. Further interview revealed if medication reconciliation was not done, the patient could be taking the wrong medication or medications would not get refilled if they ran out. 2. Record review of Patient #8's POC (certification dates 05/11/2024 to 07/09/2024), revealed a SOC date of 05/11/2024, diagnosis included Hypertensive Heart and Chronic Kidney Disease with Heart Failure. Further review of this POC revealed the frequency of SN visit was once a week for 6 weeks (1WK6). Record review of Patient #8's Client Coordination Note Report (05/22/2024) revealed LVN C noted Patient #8 would like to be seen on 05/28/2024 in the morning only between the hours of 9 -11 a.m. Further review of Patient #8's Client Coordination Note Report revealed a missed visit notification note on 05/29/2024 indicating SN missed visit, reason was no answer phone or door. Additional review of SN visits revealed no visit was attempted on 05/28/2024 (as requested by Patient #8 on 05/22/2024). During interview on 06/27/2024 at 01:44 p.m., LVN C revealed she could not recall if she attempted a visit on 05/28/2024 because she did not work that day. LVN C further revealed she informed the scheduler she would not be available on 05/28/2024 but available on 05/29/2024, but did not know if the scheduler sent someone on 05/28/2024. During interview on 06/27/2024 at 05:53 p.m., the Administrator revealed the nurse should have sent the visit back for a reschedule visit, but would depend how the request was sent back. Further interview with the Administrator revealed the nurse should have called to the office to speak with the clinical manager or scheduler to inform them the patient wanted to be seen on a specific day. The Administrator revealed not following the POC on visits was basically not following doctors orders so the patient would not get the care they needed. Record review of the agency's policy and procedure titled "Care Planning (09/2022)", read in part, "...The POC services as the patient's care-planning document...General Information: The licensed paraprofessional: will execute interventions in accordance with the POC..."