Every finding on record at Naaman Community Health Services Inc

Purpose: Recertification Survey Entrance Date: 3/16/2021 at 10:39 a.m. with the Administrator and Alternate Administrator/Supervising Nurse. Census: Licensed and Certified patient - 1 Exit Date: 3/19/2021 at 2:45 p.m. with the Administrator and Alternate Administrator/Supervising Nurse. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies.

Purpose: Recertification Survey Entrance Date: 3/16/2021 at 10:39 a.m. with the Administrator and Alternate Administrator/Supervising Nurse. Census: Licensed and Certified patient - 1 Exit Date: 3/19/2021 at 2:45 p.m. with the Administrator and Alternate Administrator/Supervising Nurse. The agency was given the opportunity to provide additional information during the survey. The preliminary findings were discussed. Written instructions were given for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies and the time frame that the agency would receive the Statement of Deficiencies. The agency meets the Conditions of Participation.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to have complete discharge summaries and failed to send the discharge summaries to the health care professionals, that would responsible for providing care and services, within 5 business days of discharge from the agency. In 6 (#2, #3, #4, #5, #6, #7) of 6 discharged patient records reviewed, the agency failed to include in the discharge summary, the list of medications that the patients were taking at the time of discharge. In 6 (#2, #3, #4, #5, #6, #7) of 6 discharge patient records reviewed, the agency failed to send the discharge summaries, within 5 business days of the patients' discharge, to the health care professionals responsible for providing care and services. The failure of the agency to have complete discharge summaries and the failure of the agency to send the discharge summaries to the health care professional responsible for providing care and services after agency discharge placed the patients at risk for over-medication, drug interactions, adverse effects from medications, duplications of medications, and other negative outcomes due to the non-continuity of care. Findings Include: Patient #2: Review of Patient #2's clinical record contained a Plan of Care dated 1/7/2019 to 3/7/2019. The Plan of Care indicated that Patient #2 started on the agency's services on 9/19/2016. The Plan of Care listed Other Specific Arthropathies Multiple Sites, Hypertension, Radiculopathy Lumbar Region, Muscle Spasm, Morbid Obesity, Iron Deficiency Anemia, Diverticulosis, History of Falls, and Vitamin D Deficiency as diagnoses. The Plan of Care listed Ibuprofen, Acetaminophen/Codeine, Losartan/Hydrochlorothiazide, Methocarbamol, Oxybutynin, Pravastatin, Temazepam, Vitamin D, Neurontin, and Lyrica as medications. Patient #2's clinical record contained an agency computerized document titled "Discharge Summary." The Discharge Summary indicated that Patient #2 was discharged on 3/5/2019 because the goals were met. Patient #2's Discharge Summary did not include a list of medications that Patient #2 was taking at the time of discharge. The clinical record contained documentation that the Discharge Summary was faxed on 5/20/2019, 76 days after discharge. Patient #3: Review of Patient #3's clinical record contained a Plan of Care dated 9/28/2019 to 11/26/2019. The Plan of Care indicated that Patient #3 started on the agency's services on 9/28/2019. The Plan of Care listed Hypertensive Heart Disease with Heart Failure, Congestive Heart Failure, Cystostomy, Peripheral Vascular Disease, Arthropathies of Multiple Sites, Muscle Wasting and Atrophy, Hyperlipidemia, and Abnormalities of Gait and Mobility as diagnoses. The Plan of Care listed Aspirin, Tylenol Extra-Strength, Metoprolol, Clopidogrel, Lisinopril, Lovastatin, Furosemide, Mupirocin, Ketorolac, Ofloxacin, and Prednisolone as medications. Patient #3's clinical record contained an agency computerized document titled "Discharge Assessment" that was dated 10/11/2019. The Discharge Assessment indicated that Patient #3 was discharged from the agency's services on 10/11/2019 due to family request as Patient #3's insurance had changed to a health maintenance organization. Patient #3's Discharge Summary did not include a list of medications that Patient #3 was taking at the time of discharge. The clinical record did not indicate that the Discharge Summary was sent to the health care professional that would be providing care and services after Patient #3's discharge from the agency. Patient #4: Review of Patient #4's clinical record contained a Plan of Care dated 12/24/2018 to 2/21/2019. The Plan of Care indicated that Patient #4 started on the agency's services on 1/3/2017. The Plan of Care listed Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney, Congestive Heart Failure, Ischemic Cardiomyopathy, Chronic Obstructive Pulmonary Disease, Arthropathies Multiple Sites, Gastro-esophageal Reflux Disease, Hypothyroidism, Chronic Kidney Disease, and Encounter for Cardiac Pacemaker as diagnoses. The Plan of Care listed Amlodipine, Aspirin, Pantoprazole, Rosuvastatin, Levothyroxine, Nitroglycerin, Lisinopril, Ipratropium Bromide, Qvar, Ergocalciferol, Furosemide, Trazodone, and Metoprolol as medications. Patient #4's clinical record contained an agency computerized document titled "Discharge Summary." The Discharge Summary was dated on 2/21/2019. The Discharge Summary indicated that Patient #4 was discharged on 2/21/2019 due to the patient's request. Patient #4's Discharge Summary did not include a list of medications that Patient #4 was taking at the time of discharge. The clinical record contained documentation that the Discharge Summary was hand-delivered on 8/28/2019, 188 days after discharge. Patient #5: Review of Patient #5's clinical record contained a Plan of Care dated 2/2/2019 to 4/2/2019. The Plan of Care indicated that Patient #5 started on the agency's services on 4/13/2017. The Plan of Care listed Hypertension, Muscle Weakness, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Localized Edema. Difficulty Walking, Constipation, Unspecified Sequelae of Unspecified Cerebrovascular Disease, Elevated Lipoprotein, and Unspecified Urinary Incontinence as diagnoses. The Plan of Care listed Spectravite, Vitamin C, Aspirin, Atorvastatin, Cetirizine, Metformin, Ventolin, Diclofenac, Bromphen Pseudo Syrup, Tylenol, Furosemide, Budesonide, Centrum Silver, Senexon, Mirtazapine, and Azithromycin as medications. Patient #5's clinical record contained an agency computerized document titled "Discharge Summary" that was dated 4/2/2019. The Discharge Summary indicated that Patient #5 was discharged on 4/2/2019 due to goals met. Patient #5's Discharge Summary did not include a list of medications that Patient #5 was taking at the time of discharge. The clinical record did not indicate that the Discharge Summary was sent to the health care professional that would be providing care and services after Patient #5's discharge from the agency. Patient #6: Review of Patient #6's clinical record contained a Plan of Care dated 9/23/2019 to 11/21/2019. The Plan of Care indicated that Patient #6 started on the agency's services on 4/6/2017. The Plan of Care listed Osteoarthritis, Diabetes Mellitus, Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Depressive Disorder, Idiopathic Peripheral Autonomic Neuropathy, Gastro-Esophageal Reflux Disease without Esophagitis, Lumbago with Sciatica, and Unspecified Asthma as diagnoses. The Plan of Care listed Amlodipine, Cipro, Gabapentin, Hydrocodone/Acetaminophen, Nitroglycerin, Potassium Chloride, Vitamin D, Ventolin, Atorvastatin, Methimazole, Ranitidine, Prednisolone, Cyclobenzaprine, Aspirin, Calcium, Tramadol, Hydralazine, Metoprolol, Chantix, Escitalopram, Metformin, and Glipizide as medications. Patient #6's clinical record contained an agency computerized document titled "Discharge Summary" that was dated 11/16/2019. The Discharge Summary indicated that Patient #6 was discharged on 11/16/2019 due to physician request. Patient #6's Discharge Summary did not include a list of medications that Patient #6 was taking at the time of discharge. The clinical record did not indicate that the Discharge Summary was sent to the health care professional that would be providing care and services after Patient #6's discharge from the agency. Patient #7: Review of Patient #7's clinical record contained a Plan of Care dated. 11/6/2019 to 1/4/2020. The Plan of Care indicated that Patient #7 started on the agency's services on 9/7/2019. The Plan of Care listed Hypertension, Lumbago with Sciatica, Intervertebral Disc Degeneration Lumbar Region, Carpal Tunnel Syndrome, Osteoarthritis, Muscle Weakness, Cervical Disc Disorder, Hyperlipidemia, Morbid Obesity, and Dependence on Wheelchair as diagnoses. The Plan of Care listed Potassium Chloride, Amlodipine, Baclofen, Furosemide, Gabapentin, Losartan, Meloxicam, Simvastatin, Tramadol, and Tylenol Arthritis Strength as medications. Patient #7's clinical record contained an agency computerized document titled "Discharge Summary" that was dated 12/31/2019. The Discharge Summary indicated that Patient #7 was discharge on 12/31/2019 due to a change in health maintenance organization insurance. Patient #7's Discharge Summary did not include a list of medications that Patient #7 was taking at the time of discharge. The clinical record did not indicate that the Discharge Summary was sent to the health care professional that would be providing care and services after Patient #7's discharge from the agency. During an interview on 3/18/2021 at 3:30 p.m. with the Administrator and Alternate Administrator/Supervising Nurse, the surveyor discussed the discharge summaries. The discharge summaries did not include a list of medications that the patients were taking at the time of discharge and that the discharge summaries and the discharge summaries weren't sent within 5 business days of the patients' discharge from the agency. The Supervising Nurse informed the surveyor that this had occurred prior to becoming the Supervising Nurse and could not give a reason why this had not been done. The Supervising Nurse did not dispute the finding.