Every finding on record at Nhc Home Care Murfreesboro

An emergency preparedness (EP) review was conducted during the recertification survey on 6/23/2025 through 6/25/2025. The facility was in complicance with EP requirements.

A recertification survey was initaited on 6/23/2025. An entrance conference was held with the Administrator. An exit meeting was held on 6/25/2025 with the following in attendance: Clinical Manager, Director of Services, Administrator, Assistant Vice President of Clinical Operations, Office Manager and Regional Administrator. The facility representatives were informed of the survey findings and provided an opportunity to ask questions.

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 policy review, observation and interview, the facility failed to ensure medications were accurately documented for 7 of 7 (Patient #1, 2, 3, 4, 5, 14 and 15) sampled patients observed during home visits. The findings included: 1. Review of the facility policy “Medication Review and Reconciliation” revised 5/22 revealed “…Purpose: To establish processes that maximize patient safety and outcomes related to medications and to comply with related state and federal regulations and best clinical practices. Policy: Medication review and reconciliation is completed as a part of all comprehensive assessments (at start of care, resumption of care, recertification and discharge) and with every medication change…Medication review and reconciliation is a multi-faceted and on-going process performed via interview and observation techniques…” 2. Medical record review for Patient #1 revealed a Start of Care (SOC) date 3/11/2025 with diagnoses including Osteoarthritis of the knee and a fractured femur. Observations in Patient #1’s home on 6/24/2025 at 12:30 PM, revealed the following medications in the home that were not documented on “Home Health Certification and Plan of Care” for the certification period from 5/10/2025 to 7/8/2025: Vitamin B-12 1000 micrograms (mcg) once daily and Vitamin D-3 1000 international units once daily. During an interview on 6/24/2025 at 12:50 PM, Patient #1 verified she was taking both Vitamin B-12 and Vitamin D-3. 3. Medical record review for Patient #2 revealed a SOC date of 6/20/2025 with diagnoses including Fracture Left Femur and Atrial Fibrillation. Review of the “Home Health Certification and Plan of Care” for the certification period from 6/20/2025-8/18/2025, revealed the following medication orders: Vitamin C (used to support the immune system) 500 milligrams (mg) 1 tablet daily Ferrous Sulfate (used to prevent and treat iron deficient anemia) 325 mg 1 tablet daily Omeprazole (used to treat gastroesophageal reflux disease) 40 mg 1 capsule daily Potassium Chloride Extended Release (used to treat low potassium) 10 milliequivalent (meq) 1 tablet daily Albuterol Sulfate Hydrofluoroalkane (HFA) (used to treat or prevent bronchospasms) 90 mcg/inhaler every four hours as needed Benzonatate (use to prevent cough) 200mg capsule three times daily as needed Ondansetron Hydrochloride (HCL) (used to prevent nausea and vomiting) 4 mg tablet every four hours as needed Observations in Patient #2’s home on 6/24/2025 at 11:30 AM, revealed the following medications were not in the patient’s home: Vitamin C 500 mg tablets, Ferrous Sulfate 325 mg tablets, Omeprazole 40 mg capsules, Potassium Chloride 10 meq. capsules, Albuterol Sulfate Inhaler HFA 90 mcg, Benzonatate 200 mg capsules and Ondansetron HCL 4mg tablets with Patient #2’s medications. During an interview on 6/24/2025 at 11:30 AM, Patient #2 stated she had been on Vitamin C 500 mg tablets, Ferrous Sulfate 325 mg tablets, Omeprazole 40 mg capsules, Potassium Chloride 10 meq capsules, Albuterol Sulfate Inhaler HFA 90 mcg, Benzonatate 200 mg capsules and Ondansetron HCL 4mg tablets while she was in the hospital. Patient #2 confirmed she has not taken them since she had been home. During an interview on 6/24/2025 at 11:45 AM, the Occupational Therapist stated that the Home Health Agency staff were supposed to review their medication list during each visit. 4. Medical record review for Patient #3 revealed a SOC date of 4/02/2025 with diagnoses including Spinal Stenosis and Multiple Myeloma. Review of the “Home Health Certification and Plan of Care” for the certification period from 4/2/2025-5/31/2025, revealed the following medication orders: Dexamethasone (used to treat inflammation) 6 mg tablet 2 tablets weekly Eliquis (used to prevent blood clots) 5mg tablet twice daily Furosemide (used to prevent swelling) 40 mg tablet daily Irbesartan (used to treat high blood pressure) 75 mg tablet daily Memantine (used for memory) 10 mg tablet twice daily Metoprolol Succinate Extended Release (ER) (used to treat high blood pressure) 50 mg tablet daily Potassium Chloride (ER) (used to treat low potassium) 20 meq tablet daily Acyclovir (used to treat shingles) 400 mg tablet twice daily Review of the Medication Administration Record from Assisted Care Living Facility (ACLF) #1 revealed the following medications were not on the POC: Albuterol HFA (used to treat bronchospasms) 90mcg every four hours as needed, Calcium (used to treat low calcium) 600 mg twice daily, Vitamin D 3 (used to treat low vitamin d) 125 mcg daily, Omeprazole (used to treat gastroesophageal disease) 20 mg daily, Oxycodone (used to treat severe pain) 5mg every six hours as needed, Robitussin (used to treat cough) 5ml every six hours as needed, Tizanidine (used to treat muscle spasms) 2 mg three times daily as needed, Trazodone (used to treat insomnia) 50 mg every night. During an interview on 6/24/2025 at 10:00 AM, the Physical Therapy Assistant stated that the Home Health Agency staff were supposed to review their medication list with the medication list from ACLF #1 during each visit. 5. Medical record review for Patient #4 revealed a SOC date of 2/18/2025 with diagnoses including Pressure Ulcer of Right Heel and Cellulitis of the Right Lower Limb. Review of the “Home Health Certification and Plan of Care” for the certification period from 6/18/2025-8/16/2025, revealed the following medication orders: Omeprazole 40 mg 1 capsule daily Bisoprolol fumarate (used to treat high blood pressure and other cardiovascular conditions) 5 mg 1 tablet daily Observations in Patient #4’s home on 6/24/2025 at 11:15 AM, revealed the following medications: Pantoprazole (used to treat heartburn and reduce the amount of acid in the stomach) 40 mg with an initial prescription date of 9/17/2024 1 capsule daily Bisoprolol/hydrochlorothiazide (HCTZ) (combination medication used to treat high blood pressure) 5 mg/6.25 mg with an initial prescription date of 1/17/2024 1 tablet daily Aspirin (anticoagulant) 81 mg over the counter (OTC) There were no omeprazole 40 mg capsules or bisoprolol fumarate 5 mg tablets with Patient #4’s medications. During an interview on 6/24/2025 at 11:25 AM, Patient #4 confirmed he took pantoprazole 40 mg 1 capsule daily and bisoprolol/HCTZ 5 mg/6.25 mg 1 tablet daily since the initial prescription date for each medication. Patient #4 confirmed he did not take omeprazole 40 mg or bisoprolol fumarate. When asked how long he had been taking aspirin 81 mg, Patient #4 stated he took 1 tablet each day for the past 10-15 years. 6. Medical record review for Patient #5 revealed a SOC date of 1/14/2025 with diagnoses including Heart Failure and Pressure Ulcer. Review of the “Home Health Certification and Plan of Care” for the certification period from 5/14/2025-7/12/2025, revealed the following medication orders: Metoprolol Succinate Extended Release (used to treat high blood pressure) 25 mg ½ tablet by mouth twice daily Observations in Patient #5’s home on 6/24/2025 at 12:40 PM, revealed the following medications: Metoprolol tartrate (non-extended-release medication used to treat high blood pressure) 25 mg ½ tablet twice daily, Potassium chloride (supplement used to treat low potassium levels) 10 meq 1 tablet daily. There were no metoprolol succinate 25 mg tablets with Patient #5’s medications. During an interview on 6/24/2025 at 12:40 PM, Patient #5 stated she had been on potassium chloride since sometime in January 2025. Patient #5 confirmed that she had been taking metoprolol tartrate which was in her medications rather than metoprolol succinate. 7. Medical record review for Patient #14 revealed a SOC date of 3/14/2025 with diagnoses including Chronic Obstructive Pulmonary Disease and Diabetes Mellitus. Review of the “Home Health Certification and Plan of Care” for the certification period from 5/13/2025-7/11/2025, revealed the following medication orders: Fentanyl Patch (used to treat severe pain) 37.5 mcg/hr every 72 hours Simethicone (used to relieve symptoms of gas) 125 mg 1 tablet daily Torsemide (used to treat edema and high blood pressure) 100 mg 1 tablet daily Review of the Medication Administration Record from ACLF #1 revealed the following medications: Fentanyl Patch 50 mcg/hr every 72 hours with an initial start date of 6/6/2025 Simethicone 125 mg 1 tablet twice daily with an initial start date of 9/5/2024 Torsemide 20 mg to be added to the torsemide 100 mg for a total of torsemide 120 mg daily with an initial start date of 6/11/2025 During an interview on 6/24/2025 at 9:50 AM, Licensed Practical Nurse #1 stated that the Home Health Agency #1 staff were supposed to review their medication list with the medication list from ACLF #1 during each visit. 8. Medical record review for Patient #15 revealed a SOC date of 4/29/2025 with diagnoses including Fracture Left Pubis and Atrial Fibrillation. Review of the “Home Health Certification and Plan of Care” for the certification period from 4/29/2025-6/27/2025, revealed the following medication orders: Cyanocobalamin (used to treat b12 deficiency) 1000 mcg sublingual daily Observations in Patient #15’s home on 6/24/2025 at 2:00 PM, revealed the following medications: Cyanocobalamin 3000 mcg sublingual daily, Centrum (used to treat or prevent vitamin deficiency) 1 tablet daily, and Hydrochlorothiazide (used to treat blood pressure) 25mg daily During an interview on 6/24/2025 at 2:00 PM, Patient #15 stated she was taking Cyanocobalamin 3000 mcg daily, Centrum tablet daily, and Hydrochlorothiazide 25mg daily. During an interview on 6/24/2025 at 2:15 PM, the Physical Therapist stated that the Home Health Agency staff were supposed to review their medication list during each visit. PT stated he would clarify the medication record with the physician. 9. During an interview on 6/25/2025 at 10:33 AM, the Administrator stated he expected the clinical staff to assess for any medication changes at each home visit and update the medication in the medical record.

An Emergency Preparedness survey was conducted from 6/8/2021 to 6/10/2021 at NHC Home Care Murfreesboro. No deficiencies were cited under CFR Part 484.22 Condition of Participation for Home Health Agencies.

A Recertification survey was conducted at NHC Home Care Murfreesboro from 6/8/2021 to 6/10/2021. Deficiencies were cited under CFR Part 484, Requirements for Home Care Organizations Providing Home Health Care.

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 agency policy, medical record review and interview the agency failed to reduce to writing verbal orders for 1 patient (#6) of 17 patients reviewed. The findings include: Review of the agency's Medication Review, Reconciliation and Management policy dated 7/2011 showed "...Physician orders are required for all medications and all medication changes..." Patient #6 was admitted to the agency on 5/6/2021 with diagnoses including Chronic Kidney Disease and Atrial Fibrillation. Medical record review of a nurse's note dated 5/13/2021 showed the patient's INR (measure of blood coagulation) was 2.0 (normal 2.0 to 3.0). A verbal order was received to continue current Warfarin (anti-coagulant) dosage and repeat the INR in 1 week. Review of physician orders showed no order was written to obtain an INR in 1 week. Medical record review of a nurse's note dated 5/19/2021 showed the patient's INR was 1.8. A verbal order was obtained to increase the Warfarin to 7.5 mg (milligrams) on 5/19/2021, then change dosage of Warfarin to 2.5 mg on Monday, Wednesday, Friday and 5 mg on all other days. Continued reviewed showed to obtain a INR next Wednesday. Review of physician orders showed no order was written to change the Warfarin dosages or to obtain an INR. Medical record review of a nurse's note dated 5/26/2021 showed the patient's INR was 2.5 and no changes in Warfarin dose. Continued review showed a verbal order to obtain an INR every Wednesday. Review of physician orders showed no order was written to obtain an INR every Wednesday. Medical record review of a nurse's note dated 6/2/2021 showed the patient's INR was 3.3. A verbal order was obtained to hold the Warfarin's dose on 6/2/2021. Review of physician orders showed no order was written to hold the Warfarin dose. Interview with the Regional Director on 6/10/2021 at 9:00 AM showed the agency failed to reduce Warfarin and INR orders to writing.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on agency policy review, medical record review and interview, the agency failed to revised the plan of care to update the medication profile with medication changes for 3 patients (#3, #6 and #8) of 17 patients reviewed. The findings include: Review of the Patient Plan of Care policy revised on 12/2017 showed "...A revised plan of care must reflect current information..." Patient #3 was admitted to the agency on 5/26/2021 with diagnoses including Orthopedic Aftercare and Parkinson's Disease. Medical record review of a physician's order dated 6/1/2021 showed an order for Carbidopa (treat symptoms of Parkinson's Disease) 25 mg. (milligrams) four times a day; Terazosin (relaxes muscles of the bladder and prostate) 2 mg. every day; and Duloxetine (anti-depressant) 90 mg. daily. Medical record review of the Medication Profile on 6/9/2021 showed the medications were not updated on the medication profile until 6/9/2021 at 4:56 PM. Patient #6 was admitted to the agency on 5/6/2021 with diagnoses including Chronic Kidney Disease and Atrial Fibrillation. Medical record review of a nurse's note dated 5/19/2021 showed the patient's INR (measures blood coagulation) was 1.8. A verbal order was obtained to increase the Warfarin (anti-coagulant) to 7.5 mg (milligrams) on 5/19/2021, then change dosage of Warfarin to 2.5 mg on Monday, Wednesday, Friday and 5 mg on all other days. Review of the medication profile showed the profile was not updated with the medication changes. Medical record review of a nurse's note dated 6/2/2021 showed the patient's INR was 3.3. A verbal order was obtained to hold the Warfarin's dose on 6/2/2021. Review of the medication profile showed the profile was not updated with the medication change. Patient #8 was admitted to the agency on 4/21/2021 with diagnoses of Anemia and Chronic Obstructive Pulmonary Disease. Medical record review of a nurse's note dated 6/1/2021 showed the physician ordered Fusion Plus Capsule (multi-vitamin), 1 tablet every day. Medical record review of the Medication Profile dated 6/9/2021 showed the medication was not updated on the medication profile until 6/9/2021 at 5:03 PM. Interview with the Regional Director on 6/10/2021 at 9:15 AM showed the agency failed to revised the plan of care with current medications at the time of the physician's order.