Every finding on record at Kah Development 4, LLC

On 08/21/2023 at 12:00 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 08/24/2023 at 11:00 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, staff interview and patient interview, the Skilled Nurse (SN) failed to include all medications the patient was currently using during a review of the patients medication regimen in 2 (#1 and #10) of 10 (#1 - #10) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for all patients on census by inhibiting the SN 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: Clinical Record #1: Revealed a document titled Client Medication Report dated 7/13/2023 showed an entry of Oxygen, 2 liters, as needed for shortness of breath. There was no documentation the oxygen had been checked by an outside drug reconciliation program. Due to the electronic medical charting system utilized by this Agency, Oxygen is a "blue highlighted" medication indicating the charting system doesn't check it for interactions against all other medications. Clinical Record #10: Revealed a certification period of 05/28/2023 through 7/26/2023 and documentation the patient was receiving outpatient chemotherapy. There was no evidence of chemotherapy medications on the clients medication report. Agency Representative #1 was asked to provide additional information. None was forthcoming.