Every finding on record at Lhcg Cxxxxii, LLC

On 12/18/2023 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 of Home Health. On 12/21/2023 at 10:00 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 Oxygen (O2)during the review of the patients medications in 2 (#5 and #8) of 13 Clinical Records reviewed. This failed practice by the SN posed a risk of potential harm for patients on the census receiving O2 therapy 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. Review of Clinical Record #5 revealed the following: 1) A document titled "Home Health Certification and Plan of Care (POC) dated 10/26/2023 through 12/24/2023 which listed a diagnosis of 'Dependence on Supplemental Oxygen" 2) document titled "Client Medication Report" listed "O2-oxygen 2 liters, intermittent." This is a "blue lined" entry (highlighted on the screen in a blue color) in the Electronic Medical Record (EMR) system used by Agency. 3) Interview with Agency Staff revealed "blue lined" entries in the patients medication list are not checked for interactions with other drugs in the EMR system. Review of Clinical Record #8 revealed the following: 1) A document titled "Home Health Certification and Plan of Care (POC) dated 10/31/2023 through 12/29/2023 which listed a diagnosis of 'Dependence on Supplemental Oxygen" 2) document titled "Client Medication Report" listed "O2-oxygen 2 liters, daily via nasal canula." This is a "blue lined" entry (highlighted on the screen in a blue color) in the Electronic Medical Record (EMR) system used by Agency. 3) Interview with Agency Staff revealed "blue lined" entries in the patients medication list are not checked for interactions with other drugs in the EMR system. Agency Staff were asked if there was any documentation of a manual or out of their EMR medication reconciliation. Per Staff #2, "No."