Every finding on record at New Millenium Home Health, LLC

Substantial Allegation Survey Substantial Allegation 32034 The following deficiency is based upon substantial allegation 32034 completed on 11/16/21. New Millenium Home Health, LLC 368112, is not in compliance with the requirements found at 42 CFR Part 484, Subpart B, C for Home Health Agencies. .

Services by skilled professionals CFR(s): 484.75(a) Standard: Provision of services by skilled professionals. Skilled professional services are authorized, delivered, and supervised only by health care professionals who meet the appropriate qualifications specified under §484.115 and who practice according to the HHA's policies and procedures. This STANDARD is not met as evidenced by: Based on interview, policy review and medical record review, the agency failed to ensure skilled nursing staff practiced according to the home health agency's policies and procedures for one of three medical records reviewed (Patient #1). The census was 113. Findings include: Review of the agency’s undated policy titled, Medication Administration, revealed agency staff will administer medications as ordered by the physician. If a patient has medications in the home and are taking them, agency staff must contact the physician to verify and document the order in the client record and on the medication profile. Agency staff should verify orders for medications prior to administering. Agency staff will identify in writing what drugs the home care nurses can administer. Prior to medication administration the nurse must verify if it is the correct medication, medication stability, expiration date, correct dose/route/time and that no contraindications exist. Review of the agency’s undated policy titled, Medication Reconciliation, revealed agency staff will reconcile all client medications prior to admission to homecare, before and after inpatient stays and at discharge. Medications will be reviewed with the client on each home visit to determine if other medications are being taken. When a client is discharged from a facility, the medications will be reviewed and the orders will be updated. Interview on 11/15/21 at 4:10 PM with Staff B revealed Staff A called off at the end of August 2021. Staff B covered the shift for Patient #1 and set up the medications in the pill reminder based off of the medication list that was sent home with the patient from the hospital. The next day Staff B stated the office called her saying the patient was sent to the hospital for an allergic reaction. The office asked her what happened during her visit on 08/30/21. She informed them that she set up the medications using the hospital medication list. Staff B stated the hospital medication list was from a recent hospital visit but she could not recall the date of the visit. Review on 11/15/21 of patient's medical record revealed a start of care date of 05/04/20 with diagnoses that include diabetes mellitus type II and chronic pain syndrome. A recertification assessment was completed by the registered nurse on 08/25/21. Review of the physician ordered plan of care dated 08/27/21 through 10/25/21 revealed the patient was to be seen daily by the skilled nurse and the home health aide was to provide 28-30 hours of services each week. Review of skilled nursing notes revealed on 08/30/21 Staff B noted that she set up the patient's medications using the hospital discharge list. Further review of the skilled nursing notes revealed the patient returned from the last hospitalization on 08/02/21. Interview on 11/16/21 at 11:00 AM with Staff C verified that Staff B noted she used the hospital medication list to set up the patient’s medications on 08/30/21. Staff C verified that the registered nurse completed the recertification assessment on 08/25/21 and verified Patient #1’s medications. Staff C verified the last hospital visit on file was from 08/02/21 until the 08/31/21 hospital admission. Staff C also verified that the medication profile should be updated with any medication change. This deficiency substantiates Substantial Allegation 32034.