Every finding on record at Lhcg Xvi, LLC

Complaint Survey #LA00113250 Abbreviations: CMS- Centers for Medicare & Medicaid Services mg- milligram ml- milliliter

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record reviews and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Findings: Review of the agency’s policy titled, “OASIS Data Capture, Transmission, Verification, Display and Reports” with a revision date of 03/01/2021, revealed the following, in part: Purpose: To ensure proper OASIS data capture and transmission to state agencies and to ensure compliance with regulatory guidelines. Procedure: 2. Transmittal of OASIS data a. At least monthly, the Agency will electronically transmit accurate, completed, encoded and locked OASIS data to the state agency. All OASIS assessments completed must be transmitted within thirty (30) days of M0090 (Date Assessment Completed) date. Review of the agency's OASIS Final Validation Report with a submission date of 12/10/2024 revealed 34 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Final Validation Report with a submission date of 01/14/2025 revealed 31 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Final Validation Report with a submission date of 01/21/2025 revealed 28 records were processed with 1 record receiving a message in which the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Final Validation Report with a submission date of 01/28/2025 revealed 45 records were processed with 2 records receiving messages in which the records were submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S1ED on 02/18/2025 at 2:45 p.m. She reviewed the above OASIS validation reports and confirmed 5 of the records were submitted late, more than 30 days after completion.

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 observations, interviews, and record reviews, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing and therapy staff reconciled patients’ medications for 2 of 2 (#1 and #2) patients reviewed with home visits. Findings: Review of the agency’s policy titled, “Monitoring Medications,” with a revision date of 07/01/2024, revealed the following, in part: Purpose: To provide a process to ensure continuous monitoring of medications in the patient’s home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. Procedure: The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. b. Review all medicaitons….to identify issues such as: viii. Noncompliance with drug therapy; ix. Dosage errors 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient’s episode of care the following will occur: a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. Patient #1 Review of Patient #1’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/24/2025, and had a current Certification Period of 01/24/2025 through 03/24/2025. Patient #1 had a diagnosis, which included Unspecified Spleen B-cell Lymphoma. Patient #1 was ordered to receive Skilled Nursing Visits once weekly for nine weeks and Physical Therapy Visits once weekly for one week. A home visit was conducted with Patient #1 on 02/17/2025 at 12:15 p.m. with S2RN present in the home. Patient #1’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Gabapentin 250 mg/5 ml oral solution take 8 ml by mouth three times daily was on the medication profile and the patient was taking once daily; and Bactrim DS (Double Strength) 800 mg-160 mg take one tablet by mouth every Monday, Wednesday and Friday was on the medication profile as discontinued on 02/05/2025 and the patient was still taking. An interview was conducted with Patient #1’s sister during the home visit. She stated she managed Patient #1’s medications and filled his pill planner weekly. She stated Patient #1 had been taking Gabapentin once daily since September 2024. She stated Patient #1 was still taking Bactrim every Monday, Wednesday and Friday. An interview was conducted with S2RN on 02/17/2025 at 1:00 p.m. during the home visit. S2RN confirmed the above medication discrepancies. S2RN confirmed the medications the patient was taking and what was on the medication list should match and did not. Patient #2 Review of Patient #2’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/25/2025, and had a current Certification Period of 01/25/2025 through 03/25/2025. Patient #2 had diagnoses, which included Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Acute on Chronic Combined Systolic and Diastolic Heart Failure, and Chronic Kidney Disease Stage 3B. Patient #2 was ordered to receive Skilled Nursing Visits once weekly for ten weeks, Physical Therapy Visits twice weekly for one week then once weekly for five weeks. A home visit was conducted with Patient #2 on 02/18/2025 at 9:05 a.m. with S3PT present in the home. Patient #2’s medications were reviewed during the home visit and the following discrepancies were identified when compared to the current Medication Profile provided by the agency: Atorvastatin 40 mg take one tablet at bedtime was on the medication profile and the patient was taking Atorvastatin 20 mg take one-half tablet by mouth at bedtime with a filled date of 02/10/2025; Furosemide 20 mg take one tablet daily times for seven days with a start date of 02/01/2025 was on the medication profile and the patient was no longer taking; Furosemide 40 mg take one-half tablet by mouth every day with a filled date of 02/10/2025 was present in the home and not on the medication profile; Hydrochlorothiazide 12.5 mg take one table daily was on the medication profile and not present in the home; Tamsulosin 0.4 mg take one capsule by mouth daily was on the medication profile and not present in the home; and Polyethylene Glycol 17 gram oral powder take 17 grams daily was on the medication profile with a start date of 01/25/2025 and the patient was not taking the medication. An interview was conducted with Patient #2’s spouse during the home visit. She stated Patient #2’s medications were managed by their daughters who filled his pill box weekly. She stated the Furosemide was changed to 40 mg take one-half tablet daily on 02/10/2025. She stated the Atorvastatin was changed to 20 mg take one-half tablet on 02/10/2025. She stated both medications were started on 02/10/2025. She stated Patient #2 had not taken Polyethylene Glycol since he came home from the hospital on 01/24/2025 because he did not need to take it. An interview was conducted with S3PT on 02/18/2025 at 9:40 a.m. during the home visit. During the interview, Patient #2’s daughter verified the Hydrochlorothiazide and Tamsulosin were stopped prior to his surgery on 01/17/2025, were not refilled and they did not have the medications in the home. S3PT stated medications should be reconciled during every home visit. S3PT verified a Skilled Nursing visit was made with Patient #2 on 02/12/2025. S3PT confirmed the medications the patient was taking and what was on the medication list should match and did not. An interview was conducted with S1ED on 02/18/2025 at 3:05 p.m. S1ED was notified of the medication discrepancies identified during the home visits for Patient #1 and #2. S1ED stated medications should be reconciled during each home visit. S1ED confirmed the medications each patient was currently taking should have matched the patient’s current medication profile.

Within 48 hours of the patient's return CFR(s): 484.55(d)(2) Within 48 hours of the patient's return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment was updated on the physician ordered resumption date after a hospital admission of 24 hours or more for 1 (#1) of 3 (#1, #2, and #3) sampled patients reviewed. Findings: Review of the agency’s policy titled, “Patient Assessment, Initial and Reassessment” with a revision date of 09/01/2024, revealed the following, in part: Procedure: 5. A qualified clinician performs a comprehensive assessment or reassessment visit in the following situations: b. A resumption of care assessment within 48 hours following post-hospitalization discharge notification or on physician ordered resumption. Review of Patient #1’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/24/2025 and had a current Certification Period of 01/24/2025 through 03/24/2025. Patient #1 had a diagnosis, which included Unspecified Spleen B-cell Lymphoma. Patient #1 was ordered to receive Skilled Nursing Visits once weekly for nine weeks and Physical Therapy Visits once weekly for one week. Review of Patient #1’s Hospital Paperwork from a local hospital revealed he was admitted to the hospital on 01/29/2025 and discharged on 02/03/2025. Further review revealed a requested resumption of care date within two to three days. Review of Patient #1’s Visit Notes for Certification Period of 01/24/2025 through 03/24/2025 revealed a Registered Nurse Resumption of Care visit was conducted on 02/07/2025. Further review of Patient #1’s Clinical Record revealed no documented evidence the physician was contacted to delay the physician ordered resumption of care date. An interview was conducted with S1ED on 02/18/2025 at 3:05 p.m. S1ED stated a patient’s Home Health services should be resumed within 48 hours of a hospital admission, unless the patient requested, or physician ordered a specific resumption of care date. S1ED stated Patient #1 was admitted to the Home Health agency on 01/24/2025 and was admitted to the hospital on 01/29/2025. S1ED stated Patient #1 was discharged home from the hospital on 02/03/2025. S1ED reviewed Patient #1’s hospital paperwork and stated the physician ordered Home Health services to be resumed within two to three days. S1ED confirmed Patient #1’s Home Health services were resumed on 02/07/2025 and there was no documentation as to why the resumption of care was delayed and there should have been.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on record reviews and an interview, the agency failed to provide services as ordered by the Practitioner in the Plan of Care for 2 (#2 and #3) of 3 (#1, #2, and #3) patient records reviewed. The agency failed to ensure S4PTA obtained respirations for Patient #2 and Patient #3 on each physical therapy visit. Findings: Review of the agency’s policy titled, “Vital Signs” with a revision date of 09/01/2024, revealed the following, in part: Purpose: To provide a mechanism of notifying the physician or authorized practitioner in sudden changes in a patient’s condition, as well as changes that occur over a lengthy period of time. Policy: Therapist will assess blood pressure, pulse and respirations at each therapy visit. Procedure: 1. For in-person visits, documentation of vital signs will be present on each clinical note. Patient #2 Review of Patient #2’s Clinical Record revealed he began receiving services from the Home Health Agency on 01/25/2025 and had a current Certification Period of 01/25/2025 through 03/25/2025. Patient #2 had diagnoses, which included Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Acute on Chronic Combined Systolic and Diastolic Heart Failure and Chronic Kidney Disease Stage 3B. Review of Patient #2’s Plan of Care for Certification Period 01/25/2025 through 03/25/2025 revealed he was to receive Physical Therapy Visits twice weekly for one week then once weekly for five weeks. Further review of Patient #2’s Plan of Care revealed the following, in part: When vital signs are obtained, licensed professionals are to report vital signs falling outside the following established parameters: Respirations less than 12 or greater than 24… Review of Patient #2’s Physical Therapy Visit note completed by S4PTA revealed no documentation of respirations on 02/04/2025. Review of Patient #2’s Vital Signs Report for Certification Period 01/25/2025 through 03/25/2025 revealed no documentation of respirations on 02/04/2025. Patient #3 Review of Patient #3’s Clinical Record revealed she began receiving services from the Home Health Agency on 11/04/2024 and was discharged on 02/10/2025. Patient #3 had diagnoses, which included Multiple Sclerosis and Anxiety Disorder. Review of Patient #3’s Plan of Care for Certification Period 11/04/2024 through 01/02/2025 revealed she was to receive Physical Therapy Visits twice weekly for two weeks then once weekly for seven weeks. Further review of Patient #3’s Plan of Care revealed the following, in part: When vital signs are obtained, licensed professionals are to report vital signs falling outside the following established parameters: Respirations less than 12 or greater than 24… Review of Patient #3’s Physical Therapy Visit notes completed by S4PTA revealed no documentation of respirations on 11/11/2024, 11/15/2024, 11/19/2024 and 11/26/2024. Review of Patient #3’s Vital Signs Report for Certification Period 11/04/2024 through 01/02/2025 revealed no documentation of respirations on 11/11/2024, 11/15/2024, 11/19/2024 and 11/26/2024. Review of Patient #3’s Plan of Care for Certification Period 01/03/2025 through 03/03/2025 revealed she was to receive Physical Therapy Visits once weekly for six weeks. Further review of Patient #3’s Plan of Care revealed the following, in part: When vital signs are obtained, licensed professionals are to report vital signs falling outside the following established parameters: Respirations less than 12 or greater than 25… Review of Patient #3’s Physical Therapy Visit notes completed by S4PTA revealed no documentation of respirations on 01/08/2025, 01/15/2025, 01/24/2025, and 02/05/2025. Review of Patient #3’s Vital Signs Report for Certification Period 01/03/2025 through 03/03/2025 revealed no documentation of respirations on 01/08/2025, 01/15/2025, 01/24/2025 and 02/05/2025. An interview was conducted with S1ED on 02/18/2025 at 3:05 p.m. S1ED stated each patient’s blood pressure, pulse, respiration, and pulse ox should be documented on each physical therapy visit and a temperature checked if the patient was symptomatic or as indicated. S1ED reviewed the above listed Physical Therapy Visit notes and Vital Signs Reports for Patient’s #2 and #3. S1ED confirmed S4PTA completed the above listed visits for Patient’s #2 and #3. S1ED confirmed S4PTA did not document Patient #2 and Patient #3’s respirations each visit and should have.

The entity is in compliance with the federal emergency preparedness requirements.

Recertification Survey Abbreviations: CMS - Center for Medicare & Medicaid Services mg - milligram PO - by mouth SQ - subcutaneous

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure each OASIS (Outcome and Assessment Information Set) was successfully transmitted to the CMS system within 30 days of completion. Review of the Agency’s Policy titled, “OASIS Data Capture, Transmission, Verification, Display and Reports” with a revision date of 03/01/2021 revealed the following, in part: Purpose: To ensure proper OASIS data capture and transmission … and to ensure compliance with regulatory guidelines. Procedure: 2. Transmittal of OASIS data a. At least monthly, Agency will electronically transmit accurate, completed, encoded and locked OASIS data... All OASIS assessments completed must be transmitted within thirty (30) days of M0090 date. Review of the agency's OASIS Agency Final Validation Report with submission date of 08/22/2023 revealed 20 records were processed with 1 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 09/27/2023 revealed 12 records were processed with 1 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 10/12/2023 revealed 30 records were processed with 9 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 10/17/2023 revealed 14 records were processed with 1 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 10/25/2023 revealed 32 records were processed with 2 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 11/22/2023 revealed 18 records were processed with 1 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 02/07/2024 revealed 34 records were processed with 2 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 02/21/2024 revealed 21 records were processed with 1 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 03/06/2024 revealed 37 records were processed with 1 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 03/13/2024 revealed 22 records were processed with 3 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. Review of the agency's OASIS Agency Final Validation Report with submission date of 03/19/2024 revealed 18 records were processed with 1 of the records receiving messages the record was submitted late due to a submission date of more than 30 days after date on the record. An interview was conducted with S1ED on 04/03/2024 at 11:55 a.m. She reviewed the above OASIS validation reports and confirmed 23 of the records were submitted late, more than 30 days after completion. She confirmed patients’ OASIS should have been submitted within 30 days of completion.

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 observations during home visits, interviews, and record review, the agency failed to ensure each patients’ comprehensive assessment included a review of all medications the patients were currently using. The agency failed to ensure skilled nursing and therapy staff reconciled patients’ medications for 3 (#5, #6, and #8) of 5 (#5, #6, #7, #8 and #9) patients reviewed with home visits. Review of the Agency’s Policy titled, “Monitoring Medications” and aa revision date of 12/01/2023 revealed the following, in part: Purpose: To provide a process to ensure continuous monitoring of medications in the patient’s home. Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. Procedure: The discipline responsible for the drug regimen review will: Compare medication list obtained from the facility from which the patient was transferred and/or physician orders to actual medications patient is taking. Review all medicaitons….to identify issues such as: ix. Dosage errors 2. All clinicians participating in the patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout the episode of care. During the patient’s episode of care the following will occur: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. Patient #5 Review of the Clinical Record for Patient #5 revealed she began receiving services from the Home Health Agency on 03/22/2024 and had a current Certification Period of 03/22/2024 to 05/20/2024. Patient #5 had diagnoses, which included Pulmonary Embolism Without Acute Cor Pulmonale and Unspecified Abnormalities of Gait and Mobility. Further review revealed Patient #5 was ordered to receive Skilled Nursing Visits once weekly for nine weeks for Certification Period of 03/22/2024 to 05/20/2024. A home visit was conducted with Patient #5 on 04/01/2024 at 2:30 p.m. with S4PTA present in the home. Patient #5’s medications were reviewed during the home visit. The following medication discrepancy was identified when compared to Patient #5’s Current Medication Profile provided by the Home Health Agency: Metoprolol Tartrate 50 mg tablet take 1 tablet by mouth daily was on medication profile with a start date of 03/22/2024. Medication bottle present in the home with a filled date of 11/11/2023 with instructions to take Metoprolol Tartrate 50 mg tablet, 1 tablet by mouth twice daily. An interview was conducted with Patient #5 during the home visit. She stated she used to manage her medications, but since returning from the hospital her daughter had been filling her pill box. She stated she still knew what medications she takes. She stated she had taken Metoprolol 50 mg tablet 1 tablet twice daily, in the morning and at night, for a long time. A telephone interview was conducted with Patient #5’s daughter on 04/01/2024 at 3:15 p.m. She stated she managed Patient #5’s medications since she came home from the hospital. She confirmed Patient #5 had been taking Metoprolol 50 mg 1 tablet twice daily for a while. An interview was conducted with S4PTA on 04/01/2024 at 3:30 p.m. He stated the nurses were responsible to reconcile patients’ medications and bottles every visit. He verified the medication, Metoprolol, on Patient #5’s Medication Profile and what the patient was taking did not match and should have. Patient #6 Review of Patient #6’s Clinical Record revealed she began receiving services from the Home Health Agency on 02/24/2024 and had a current Certification Period of 02/24/2024 to 04/23/2024. Patient #6 had diagnoses, which included Disruption of External Operation (Surgical) Wound, Encounter for Other Orthopedic Aftercare, and Thromboangitis Obliterans, and Long Term (Current) use of Anticoagulants. Further review revealed Patient #6 was ordered to receive Skilled Nursing Visits once a week for one week, three times weekly for eight weeks, and once a week for one week for Certification Period of 02/24/2024 to 04/23/2024. A home visit was conducted with Patient #6 on 04/01/2024 at 2:00 p.m. with S2RN present in the home. Patient #6’s medications were reviewed during the home visit. The following medication discrepancies were identified when compared to Patient #6’s Current Medication Profile provided by the Home Health Agency: Coumadin 10 mg take one by mouth daily was on the medication profile, and patient no longer taking. Enoxaparin 80 mg subcutaneously daily was on the medication profile, and patient no longer taking. Coumadin 5 mg by mouth every Monday, Wednesday, and Friday was present in the home and not on the medication profile. Coumadin 2.5 mg by mouth every Tuesday, Thursday, Saturday, and Sunday was present in the home and not on the medication profile. An interview was conducted with Patient #6 during the home visit. She stated she had not taken Coumadin 10 mg in at least one month. She stated she had been taking 5 mg every Monday, Wednesday, and Friday and 2.5 mg every Tuesday, Thursday, Saturday, and Sunday. She stated she had not taken Enoxaparin in a few months. An interview was conducted with S2RN during the home visit. S2RN confirmed the above medication discrepancies during the home visit. S2RN stated medications should be reconciled during every home visit. Patient #8 Review of the Clinical Record for Patient #8 revealed he began receiving services from the Home Health Agency on 02/20/2024 and had a current Certification Period of 02/20/2024 to 04/19/2024. Patient #8 had diagnoses, which included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Hypertensive Heart Disease with Heart Failure, and Sciatica. Further review revealed Patient #8 was ordered to receive Skilled Nursing Visits once weekly for nine weeks for Certification Period of 02/20/2024 to 04/19/2024. A home visit was conducted with Patient #8 on 04/02/2024 at 8:30 a.m. with S3LPN present in the home. Patient #8’s medications were reviewed during the home visit. The following medication discrepancy was identified when compared to Patient #8’s Current Medication Profile provided by the Home Health Agency: Prednisone 20 mg take 2 tablets by mouth daily with a start date of 02/19/2024 and no stop date was on medication profile and not present in the home. Review of the typed medication list dated 03/01/2024 located with Patient #8’s medication bottles revealed Prednisone 20 mg take 2 tablets by mouth daily times 5 days. An interview was conducted with Patient #8 during the home visit. He stated his daughter filled his pill box weekly. He stated he was prescribed Prednisone after his hospitalization in February 2024. He stated he stopped taking Prednisone “a while ago.” An interview was conducted with S3LPN during the home visit on 04/02/2024 at 9:05 a.m. She stated the nurses should reconcile the patients’ medications and bottles every visit. She reviewed Patient #8’s electronic medication list and confirmed the above medication discrepancy. She stated a duration should have been entered for the Prednisone, and the medication should have been discontinued once the patient completed the 5 day course. A telephone interview was conducted with Patient #8’s daughter on 04/03/2024 at 8:05 a.m. She stated she managed Patient #8’s medications and filled his pill box weekly. She stated Patient #8 was prescribed Prednisone for only a couple days in February 2024. An interview was conducted with S1ED on 04/02/2024 at 10:20 a.m. She was notified of the medication discrepancies found during the home visits for Patient #5, #6, and #8. She stated each patients’ medications should have been reconciled every discipline visit, and nursing should review the medication bottles each visit. She verified each patients’ Medication Profile should have reflected what the patient was currently taking.

Recertification Survey COVID-19 Focused Infection Control Survey with no deficiencies cited. Abbreviations: 485/PoC- Plan of Care EDN- Executive Director of Nursing mg- milligrams SOC- Start of Care

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 observations during home visits, staff interview, and record review, the agency failed to ensure the patient's comprehensive assessments included a review of all medications the patients were currently using. The agency failed to ensure therapy and skilled nursing staff reconciled a patient's medications during subsequent home visits for 3 (#1, #3, #4) of 4 (# 1, #2, #3, #4) sampled patients who had home visits. Findings: Review of the agency's policy and procedure titled "Monitoring Medications", presented by S1EDN as current, revealed in part the following: Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skill nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode. The therapist may collaborate with the Patient Care Manager to complete the process. The physician is contacted immediately if any discrepancies between agency information and patient medications are found. Patient #1 Review of the 485/PoC for Patient #1 revealed the patient had a SOC of 09/20/2021 with diagnoses that included Fracture of the left femur, Chronic Kidney Disease Stage 3, Chronic Diastolic Heart Failure and history of falling. The patient was certified to receive services from 09/20/2021 to 11/18/2021. A review of Patient #1's Medication Report revealed the following medications: Alprazolam 0.5 mg disintegrating tablet daily Hydralazine 25 mg tablet 3 times daily Nifedipine ER 30 mg tablet, Extended Release A home visit was conducted with Patient #1 on 10/11/2021 at 2:15 p.m. A review of the patient's medications regimen was conducted at that time and the following was observed on the patient's medication bottles: Alprazolam 0.5 mg disintegrating tablet take 2 times daily as needed Hydralazine 100 mg tablet three times a day, Medication was dispensed on 07/19/2021 Nifedipine ER 60 mg tablet daily, Medication was dispensed on 03/09/2021 An interview was held with Patient #1 on 10/11/2021 at 2:25 p.m. The patient was knowledgeable of all of the medications she was taking and verified she was taking them as prescribed on her medication bottles. Patient #3 Review of the 485/PoC for Patient #3 revealed the patient had a SOC of 09/03/2021 with a diagnosis that included Disruption of External Operation (surgical) wound. The patient was certified to receive services from 09/03/2021 to 11/01/2021. A review was made of Patient #3's medication report revealed the patient was taking Atorvastatin 40 mg tablet daily. A home visit was conducted with Patient #3 on 10/12/2021 at 9:05 a.m. A request was made to review the patient's medication bottles and the following was observed: Rosuvastatin 10 mg tablet take once daily, Medication dispensed 08/15/2019 There was no medication bottle available to show the patient was currently taking Atorvastatin. An interview was held with Patient #3 10/12/2021 at 9:10 a.m. He stated he used to take Atorvastatin but they changed his medication to Rosuvastatin but was unsure when. Patient #4 Review of the 485/PoC for Patient #4 revealed the patient had a SOC of 09/15/2021 with diagnoses that included Hypertensive Heart Disease, Acute Chronic Diastolic Heart Failure, DM II, Dysarthria following Cerebral Infarct, Dysphagia following cerebral infarct, History of Falling. The patient was certified to receive services from 09/15/2021 to 11/13/2021. A review of Patient #4's current medication report revealed there was no documentation showing the patient was taking Omnicef and Aspirin. A home visit was conducted for Patient #4 on 10/12/2021 at 10:30 a.m. A request was made to review the patient's current medications. Patient #4 provided a bag of medications bottles for review and following was observed: Dispense Date: 06/03/2021- Omnicef 300 mg three times a day Aspirin 81 mg tablets An interview was held with Patient #4 on 10/12/2021 at 10:45 a.m. She stated she took the aspirin daily. When asked if she was currently taking the Omnicef, she stated she took it sometimes. An interview was held with S1EDN on 10/13/2021 at 11:00 a.m. She reviewed current medication lists for Patient #1, #3 and #4. She verified the medications should match the list. She verified the staff were to review the medications frequently and ensure the list matched the medications the patient was taking.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interviews and record reviews, the agency failed to ensure the plan of care was signed and dated by the patient's physician in a timely manner for 3 ( #3, #7 and #9 ) of 10 (#1-#10) sampled patients. Cross-referenced with State Regulations 9123. Patient Care Standards: C. Plan of Care. The plan of care for each patient must be individualized to address the patient's problems, goals, and required services. 1. The Plan of Care, telephone and/or verbal orders must be signed by the physician within a timely manner, not to exceed 30 days. Findings: Review of the agency policy titled "Physician Orders" revealed the following: Purpose: To outline the process of receiving and documenting physician orders. Procedure: The plan of care, telephone and or verbal orders must be signed by the physician within a timely manner per state regulations. State: Louisiana Timeliness of Physician signature: 30 days Patient #3 Review of the clinical record for Patient #3 revealed a start of care date of 09/03/2021. Review of the plan of care for the certification period 09/03/2021 - 11/01/2021 for the patient revealed a diagnosis of Disruption of External Operation (Surgical) Wound. Further review of the plan of care for this certification period revealed it was not signed by the physician. Patient #7 Review of the clinical record for Patient # 7 revealed a start of care date of 06/18/2021. Review of the plan of care for the certification period 08/17/2021 - 10/15/2021 for the patient revealed diagnoses which included Disruption of Traumatic Injury, Wound Repair, Laceration without Foreign Body, Right Lower Leg, Chronic Kidney Disease, and Acute Kidney Failure. Further review of the Plan of Care revealed a physician signature dated 09/20/2021 which was greater than 30 days from the start of the certification period. Patient #9 Review of the clinical record for Patient #9 revealed a start of care date of 04/30/2021. Review of the plan of care for the certification period 04/30/2021 - 06/28/2021 for the patient revealed diagnoses which included Hemiplegia following Cerebral Infarct, Essential Primary Hypertension, Diabetes Mellitus Type 2, and Chronic Kidney Disease. Further review of the plan of care for this certification period revealed a physician signature dated 06/09/2021 which was greater than 30 days from the start of the certification period. On 10/13/2021 at 11:00 a.m., an interview was conducted with S1EDN. After reviewing the plan of care for Patient #3, she verified the physician had not signed the plan of care. She verified the plan of care had not been signed by the physician within the required time frame for Patient #7 and #9. She said she was responsible for ensuring the patient's plan of care was signed by the physician timely.