Every finding on record at Kah Development 4, LLC

. On 1/3/2023 at 11:15 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 1/5/2023 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 and staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications during the review of the patients medications in 3(#5, #9, and #10) of 10 (#1 - #10) Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for all 106 patients on census 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. A review of Clinical Record #5 revealed the following: A. Document titled " Home Health Certfication and Plan of Care", dated 11/30/22 to 1/28/23 with a primary diagnosis of "Malignant Neoplasm of Right Lung." (Lung Cancer) B. Document titled " Visit Note Report" dated 11/20/22 showed documentation by the Skilled Nurse (SN) that Patient #5 "has chemo (chemotherapy, medications utilized to treat cancer) infusions with [named facility]." There was no evidence the chemotherapy medications were included on the current medication profile and that the chemotherapy medications were reviewed by the SN for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 2. A review of Clinical Record #9 revealed the following: A. Document titled " Client Medication Report" in which a medication, Promethazine gel (topical medication that is used to treat nausea and vomiting) was listed and highlighted in the color blue. The blue highlighting indicates this medication was included in a review of all medications for potential adverse effects, drug reactions, significant side effects or significant drug interactions. 3. During an interview on 11/5/23 at 10::30 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 patients were currently using during a review of medications. .

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on Clinical Record review and staff interview, it was determined the Agency staff did not follow the Attending Physician orders contained in the Plan of Care (POC) for 1 (#7) of 10 (#1 - #10) Clinical Records reviewed. This failed practice if not corrected had the potential of increased risk of rehospitalizations due to disease exacerbation for all patients with a diagnosis of heart failure. This deficient practice is a repeat of Agency re-certfication survey completed on 10/9/2019. A review of Clinical Record #7 revealed the following: A. Document titled, "Home Health Certification and Plan of Care", dated 12/16/22 to 2/15/22 showed a primary diagnosis of "Hypertensive Heart Disease with Heart Failure" and Physician orders for"SN to "observe/assesscardiovascular system, identify changes, and intervene to minimize complications" and to report weight gain of 2-3 LBS (pounds)/day or 5lbs/wk (week)" A review of a document titled "Vital Signs Report" showed Patient's weight at 202 on 12/28/22 and on 12/30/22 weight was 210, an 8 pound weight gain in 2 days. There was no evidence the 8 pound weight gain was reported to physcian as ordered. B. During an interview on 1/5/23 at 10:30 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's failure to provide interventions and notify the Physician of significant findings as ordered in the individualized POC for Patient #7.