Every finding on record at Prime Home Health of Lee County, LLC

A Recertification Survey was conducted on 11/28/22 to 11/30/22, and Prime Home Health of Lee County was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted at Prime Home Health of Lee County on 11/28/22 through 11/30/22, standard level deficiencies were cited and will require a plan of correction.

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 observations, review of agency policy and procedure, medical records (MR) and interviews with staff, it was determined the agency failed to update the Medication Summary (MS) per policy. This deficient practice affected two of thirteen MR reviewed including Home Visit (HV) # 1 and HV # 4 and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Medication Reconciliation Date Revised: October 2017 Policy: The Agency will reconcile patient's medications at time of admission and on an ongoing basis. Purpose: To define the medication reconciliation process Procedure: At time of admission, the admitting registered nurse (RN), physical therapist (PT), or speech therapist (SLP) will create and document a complete list of medications that patient is taking at home, including dose, strength, route and frequency... Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient's medication list in the home will also be updated... 2. HV # 4 was admitted to the agency on 10/25/22 and was certified for care 10/25/22 to 12/23/22 with diagnoses including Other Sequelae of Cerebral Infarction and Weakness. Review of the HHPSS included Plan of Care (POC) dated 10/25/22 revealed SN visits one time per week for nine weeks. PT visits one time per week for one week, two times per weeks for two weeks, and one time per week for two weeks. A HV was conducted on 11/29/22 at 8:15 AM to observe care provided by EI # 4, RN. During the HV the MS was compared to HV # 4's medications in the home. Review of the MS revealed Amlopidine 5 mg one tablet daily. HV # 4 reported he/she stopped the medication two weeks ago. In an interview conducted on 11/30/22 at 2:00 PM, EI # 1 confirmed the staff failed to ensure HV # 4's MS was updated per policy. 1. HV # 1 was admitted to the agency on 10/26/22 and certified for care 10/26/22 to 12/24/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System and Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris. Review of the Home Health Patient Status Summary (HHPSS) dated 10/26/22 revealed skilled nurse (SN) visits one time per week for nine weeks. PT visits one time per week for five weeks. A HV was conducted on 11/28/22 at 1:35 PM to observe the care provided by Employee Identifier (EI) # 6, PT. During the visit, medication reconciliation was performed with the patient using the agency MS and medications found in the home. The following medications were found in the home, verified by the patient and not documented on the MS. (a) Tylenol Extra Strength 500 milligram (MG) tablets, take two every eight hours as needed for pain. The patient stated he/she has been taking the medication for two to three weeks, "because I did not want to keep taking that Oxycodone." (b) Nicotine Transdermal Twenty Four Hour Patch 14 mg. The patient stated he/she has been using the patch to quit smoking for the past two months, "ever since I was in the hospital for my heart surgery, I have been on those patches." An interview conducted on 11/30/22 at 2:05 PM with EI # 1, Director, who confirmed the staff failed to ensure HV # 1 MS was updated per policy.