Every finding on record at Medical Management Plus LLC

Unannounced visits were concluded at Medical Management Plus on 6/17/21, 6/18/21 and 6/21/21 for the purpose of recertification and a complaint investigation (CT#30191).

Receive all services in plan of care CFR(s): 484.50(c)(5) Receive all services outlined in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical review, facility documentation review, staff interviews and policy review for one of three sampled patients reviewed for care & services (Patient #8), the facility failed to ensure the patient received services in accordance with the plan of care. The finding includes: Patient #8 had a start of care date of 10/21/19. The patient's diagnoses included major depressive disorder, anxiety disorder, pain, type II diabetes mellitus, asthma and hypertension. Review of the physician orders for the certification periods during the period of 6/27/2020 to 8/25/2020 included nursing visits two times daily for assessments and medication management. Review of the clinical record during the period of 6/12/20 through 7/8/20 failed to identify that one home visit was made on 7/8/20 to administer the patient's medication as prescribed. The clinical record lacked evidence that Patient #8's physician was notified of the missed visit. The facility was unable to locate medication administration records for the month of July 2020. An interview with the Agency Administrator on 6/17/21 at 12:15PM identified an investigation was initiated when they received the complaint on 7/7/20 that home visits were not being made. The Clinical Supervisor made a home visit to Patient #8 on 7/7/21 with a newly assigned nurse and to change the lock on Patient #8's medication box. A call was made to LPN #1 on 7/8/20 by the Administrator to ask if she had completed a home visit for Patient #8 (on 7/8/20) in which LPN #1 stated yes and was unaware the lock had been changed on the medication box. The Administrator notified her she could not have completed medication administration as the lock was changed to which LPN #1 reiterated she had made the visit. Interview with the Agency Administrator and Business Office Manager on 6/18/21 at 1:00PM identified LPN #1 was terminated for stating she had completed the 7/8/20 visit when she had not completed it. Additionally, RN #1 was terminated for failure to create Medication Administration Records for Patient #8 during the month of July 2020. This rendered an inability for LPN #1 and RN #1 to document medications administered to Patient #8. Interview with LPN #1 on 6/23/21 at 9:45AM stated she had made all of her scheduled visits for Patient #8 for the time period of 6/12/21- 7/8/21. She further stated "honestly it was so long ago I don't remember much. I remember they brought me into the office to talk about that (missed visits) but I don't remember when or what it was about". She further identified "we are dealing with a mentally ill patient, the only time I missed a visit was when she was in the hospital. A review of the Missed Visit Policy dated 8/12/19 identified the Clinical Manager and the Physician must be notified if the visits fall below the visit frequency on the plan of care.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on clinical review, facility documentation review, and staff interviews, for one of three sampled patients reviewed for complete and accurate medical records (Patient #8), the facility failed to ensure the record included documentation that the physician was notified when a visit was missed, and documentation that medication was administered in accordance with physician's orders. The finding includes: Patient #8 had a start of care date of 10/21/19. The patient's diagnoses included major depressive disorder, anxiety disorder, pain, type II diabetes mellitus, asthma and hypertension. Review of the physician orders for the certification periods during the period of 6/27/2020 to 8/25/2020 included nursing visits two times daily for assessments and medication management. 1. Review of the clinical record during the period of 6/12/20 through 7/8/20 failed to identify that one home visit was made on 7/8/20 to administer the patient's medication as prescribed. The clinical record lacked evidence that Patient #8's physician was notified of the missed visit. 2. The facility was unable to locate medication administration records for the month of July 2020. An interview with the Agency Administrator on 6/17/21 at 12:15PM identified an investigation was initiated when they received the complaint on 7/7/20 that home visits were not being made. The Clinical Supervisor made a home visit to Patient #8 on 7/7/21 with a newly assigned nurse and to change the lock on Patient #8's medication box. A call was made to LPN #1 on 7/8/20 by the Administrator to ask if she had completed a home visit for Patient #8 (on 7/8/20) in which LPN #1 stated yes and was unaware the lock had been changed on the medication box. The Administrator notified her she could not have completed medication administration as the lock was changed to which LPN #1 reiterated she had made the visit. Interview with the Agency Administrator and Business Office Manager on 6/18/21 at 1:00PM identified LPN #1 was terminated for stating she had completed the 7/8/20 visit when she had not completed it. Additionally, RN #1 was terminated for failure to create Medication Administration Records for Patient #8 during the month of July 2020. This rendered an inability for LPN #1 and RN #1 to document medications administered to Patient #8. Interview with LPN #1 on 6/23/21 at 9:45AM stated she had made all of her scheduled visits for Patient #8 for the time period of 6/12/21- 7/8/21. She further stated "honestly it was so long ago I don't remember much. I remember they brought me into the office to talk about that (missed visits) but I don't remember when or what it was about". She further identified "we are dealing with a mentally ill patient, the only time I missed a visit was when she was in the hospital. Review of facility documentation identified RN #1 had not documented medication administration for several patients on his/her visit list for the time period of 6/13/20 to 7/5/20. The facility documentation further identified that RN#1 disclosed having a "bad habit" of not signing the Medication Kardex. Multiple attempts to interview RN #1 was unsuccessful.