Every finding on record at Lawrence County Health Dept

The Emergency Preparedness requirements were evaluated, in conjunction with the recertification survey, on 02/09/23. The Agency was in compliance with the Condition, 42 CFR 484.102, Establishment of the Emergency Program (EP), for this survey.

A recertification survey was conducted on 02/09/23. The Agency was not in compliance with Standards for Home Health Agencies, 42 CFR 484, as evidenced by: Abbreviations: E - employee Pt - patient HHA - Home Health Agency mg - milligram SOC - Start of Care OTC - over the counter

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, document review and interview, it was determined for 1 of 3 (Pt #2) patient, where home visits were conducted, the Home Health Agency (HHA) failed to compare all medications to the current medication profile to ensure the patient was taking the correct medication(s). This has the potential to affect all patients receiving care from an Agency with a current census of 42 patients. Findings Include: 1. On 02/07/23 at approximately 1:15 PM, a home visit was conducted at Pt #2's home. A review of Pt #2's medication bottles revealed the patient was taking Metformin (diabetic prescription medication) 500 milligrams (mg), 1 1/2 tablets 2 times a day. 2. On 02/07/23 at approximately 2:00 PM, the medical record of Pt #2 was reviewed. Pt #2 was admitted on 01/27/23 with the primary diagnoses of encounter for surgical aftercare following surgery of the circulatory system (status post right brachial embolectomy [removal of blood clot in arm]) with an additional diagnosis of Type 2 Diabetes. The Hospital discharge medication list included "Metformin 500mg tablet, take 1 and 1/2 tablets by mouth twice a day. The "Medication Profile" and the Plan of Care for certification period 01/27/23 - 03/27/23 did not include Metformin. 3. On 02/09/23 at approximately 9:30 AM, the HHA policy "Medication Review and Documentation" (dated 2020) was reviewed. It reads "Procedure: A) The comprehensive assessment is completed on all home health patients at the initial visit. It includes an assessment of all medications the patient is taking, including OTC (over the counter) medications... D) Included in the SOC (start of care) order generated at the initial assessment visit will be a copy of the medication profile and then the medications will be listed on the Plan of Care (485) .... G) On subsequent nursing visits the RN will review the patient's medications... Th RN will note the medications in the patient char/medication record." 4. On 02/07/23 at approximately 3:30 PM, an interview with the Director of Home Health (E #1) was conducted. E #1 confirmed the Medication Profile and the Plan of Care for Pt #2 did not include the medication Metformin. E #1 stated "I started her care and just forgot to put the Metformin on the list. I know she's on it."