Every finding on record at North Carolina In-Home Partner LLC

An onsite recertification survey was conducted 3/17/25-3/18/25. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 3/17/25-3/18/25. A deficiency to the Medicare Conditions of Participation was identified.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on policy review, observation, client record review, and patient interview, the agency failed to include all medications on the plan of care for 2 of 4 home visits conducted (6 &7). Findings included: Review of a policy “Monitoring Medications”, revised 7/1/2024 was received from the agency director on 3/18/25 at 3:24 PM. The policy stated, “… the discipline responsible for the drug regimen review will review all medications…” 1. Patient #6 was admitted on 2/24/25 with diagnoses of aftercare following joint replacement surgery, unilateral primary osteoarthritis of right knee, and presence of left artificial knee joint. Orders were for physical therapy 2 times a week for 2 weeks and 1 time a week for 6 weeks. A home visit was conducted on 3/18/25 at 9:30 AM with the physical therapist assistant. A review of current medications was conducted with the patient during the home visit. The review revealed the following medication was not listed on the plan of care: Antarctic krill oil 500mg (milligrams) (used to lower blood pressure and cholesterol) take 1 tablet daily by mouth. Interview with the patient on 3/18/25 at 9:50 AM revealed, “I have been taking this for 3-4 months”. 2. Patient #7 was admitted on 2/13/25 with diagnoses of chronic heart failure, type 2 diabetes mellitus, and chronic kidney disease. Orders were for physical therapy 2 times a week for 1 week and 1 time a week for 3 weeks. A home visit was conducted on 3/18/25 at 1:30 PM with the physical therapist. A review of the current medications was conducted with the patient during the home visit. The review revealed the following medication was not listed on the plan of care: Probiotic gummy 3-N-1 take two gummies daily for abdominal health. Interview with the patient on 3/18/25 at 1:45 PM revealed, “I’ve been taking these for a couple of years”.