Every finding on record at Jordan Home Health Care, LLC

. On 7/12/2022 at 11:20 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 the Conditions of Participation for Home Health. On 7/15/2022 at010:00 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 4 (#2, #4, #5, and #6) of 7 (#1 - #7) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on census and 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. 1. A review of Patient #2 Clinical record contained the following: A. A document titled "Home Health Certification and Plan of Care" (POC) dated 6/17/2022 to 8/15/2022 showing a pertinate diagnosis (dx) of "Dependence on supplemental Oxygen." B. A document titled "Client Medication Report" ( a document used by the Agency to list all medications Patient #2 was currently taking), showed Oxygen (O2) listed and highlighted in blue. The blue highlighted medications were not included in the medications review related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 2. A review of Patient #4 Clinical record contained the following: A. A document titled "Home Health Certification and Plan of Care" (POC) dated 5/29/2022 to 7/27/2022 showing a pertinate dx of "Dependence on supplemental Oxygen." B. A document titled "Client Medication Report" listed all medications Patient #4 was currently taking and showed O2 listed and highlighted in blue. The blue highlighted medications were not included in the medications review related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. C. Further review of Patient #4's Medical Record revealed that the Client Medication Report listed a drug "Potassium Chloride Oral Solution 10% ( a drug used for to prevent and to treat low potassium levels in the body. It is a supplement that important for the heart muscless and nerves). Potassium chloride was highlighted on the Client Medication Report in blue and therefore not checked by the SN for potential adverse effects, drug reactions, signicant side effects or significant drug interactions. 3. A review of Patient #5 Clinical record contained the following: A. A document titled "Home Health Certification and Plan of Care" (POC) dated 5/31/2022 to 7/29/2022 showing a pertinate dx of "Dependence on supplemental Oxygen." B. A document titled "Client Medication Report" listed all medications Patient #5 was currently taking and showed O2 listed and highlighted in blue. The blue highlighted medications were not included in the medications review related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 4. A review of Patient #6 Clinical record contained the following: A. A document titled "Home Health Certification and Plan of Care" (POC) dated 3/24/2022 to 5/22/2022 showing a pertinate dx of "Dependence on supplemental Oxygen." B. A document titled "Client Medication Report" showed O2 listed and highlighted in blue. The blue highlighted medications were not included in the medications review related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 5. During an interview on 7/15/2022 at 9:00 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 all medications the patient #2, #4, #5, and #6 were currently taking during a review of medications. Agency Personnel #2 confirmed medications highlighted in blue on the Client Medication Report were not reviewed by there electronic medical record automatically and stated the Agency currently doesn't have a policy or process in place for medications highlighted in blue on the Client Medication Report for the SN to review related ptential adverse effects, drug reactions, significant side effects, or significant drug interactions.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on Clinical Record review and staff interviews, it was determined the Skilled Nurse (SN) staff did not accurately document care provided including all interventions in 1 (#3) of 7 (#1 - #7) Clinical Records reviewed. The deficient practice identified, resulted in an inaccurate and incomplete Clinical Record and if continued had the potential to inhibit interventions according to doctors' orders and attainment of goals specific to the patients needs. 1. Review of Clinical Record #3 revealed the following: A. Document titled "Home Health Certification and Plan of Care (POC) dated 6/25/2022 to 8/23/2022. The POC contained orders for "Home Health Aide Services for assistance with personal care and ADL's (Activities of Daily Living)". There was no documentation in the medical record that aide services were ever rendered to Patient #3. B. During a phone interview with Patient #3 on 7/13/2022 at 2:00 P.M. the patient stated aide services were provided "occasionally". Patient #3 also stated the aide services were provided by the SN when in the home providing skilled care to the patient. 2. During staff interview on 7/15/2022 at 9:00 AM, staff member #1 stated aide services are provided by a SN when there is no aide discipline available to provide these types of services to a patient. Staff members #1 and #2 confirmed there was no documentation of aide services in the medical record except an Aide POC.