Every finding on record at Pennsylvania In-Home Partner-III, LLC

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 1/29/2024, Nason Hospital Home Health Agency was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies – Emergency Preparedness.

Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 1/29/2024, Nason Hospital Home Health Agency was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 a review of agency policy and procedure, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to address significant side effects, drug interactions for two (2) of thirteen (13) MR’s reviews conducted (MR7 and MR10). Findings Included: Review of agency policy and procedures on 1/26/2024 at approximately 1:00 PM revealed, “Medication Reconciliation Tip Sheet, Home health and hospice employees will use this tip sheet to ensure compliance with the Medication Reconciliation process throughout the patient’s episode of care. For easier on-the-go reference, print document using one-page front and back. MEDICATIONO RECONCILIATION PROCESS…Verify scheduled medications have an indication for use within the medical record. It does not have to be within the order. It may be on the H&P, hospice discharge summary, etc. Make note of ANY of the following: *Potential adverse effects/drug reactions *Ineffective drug therapy *Side effects *Drug Interactions (Note: all Level 1 & Level 2 interactions MUST be reported to the Provider) *High Risk Drugs *You MUST provide and document that education has been given to the patient/Caregiver on All high-risk medications as “high risk” on the medication sheet *Duplicate drug therapy *Noncompliance *Dosing errors *Drug instabilities *Notify the Provider of ALL issues/discrepancies found. Documentation needs to reflect that the issue(s) and/or discrepancies were discussed. Be Specific and list the medications in question. MEDICATION RECONCILIATION-ROLES & RESPONSIBILITIES For patients receiving Skilled Services: *The therapist is responsible for medication reconciliation. *The therapist will collaborate with team leader to complete the process.” MR7 chart review was conducted on 1/25/2024 at approximately 1:15 PM, a review of the plan of care listed the start of care 10/19/2023 for a current certification period starting 12/18/2023 to 2/15/2024. The primary diagnosis was hypertensive health disease with heart failure. The agencies "Client Medication Report" list "Client Allergies ADHESIVE TAPE, AMOXICILLIN, LISINOPRIL.” Review of the patient authorizations document revealed “ALLERGIES...AMOXICILLIN Origin: 2022-10-18 Verified: 2022-10-18, DICYCLOMINE Origin: 2020-11-13 Verified: 2020-11-13, LISINOPRIL Origin: 2019-04-26 Verified: 2019-04-26…”The following allergy was not listed on the agency client medication report: DICYCLOMINE. MR10 chart review was conducted on 1/26/2024 at approximately 9:50 AM, a review of the plan of care listed the start of care 6/20/2023 for a current certification period starting 12/18/2023 to 2/15/2024. The primary diagnosis was hypertensive health disease with heart failure. The agencies "Client Medication Report" list "Client Allergies DEMEROL, QUESTRAN, STRAWBERRIES, SULFA WELLBUTRIN…” Review of the history and physical document within the MR listed “…Allergies: Allergies allergen Demerol [Meperidine] Reactions Low BP Other (see comments) *Rocephin [Ceftriaxone] Rash…” The following allergy was not listed on the agency client medication report: Rocephin. An exit interview was conducted with the administrator 1/29/2024 at approximately 2:00 PM which confirmed the above findings.