Every finding on record at Prohealth Home Health-Georgia, LLC

A standard survey was conducted at Ultra Care of Georgia in Columbus, GA, on 3/3/22. The agency was in compliance with 42 CFR Part 484.22, Emergency Preparedness for Home Health Agencies. A Covid 19 Focused Infection Control Survey was also completed at the time of the on-site survey. The census was 116 at the time of the on-site visit. No deficiencies were cited.

A standard survey was conducted at Ultra Care of Georgia in Columbus, GA, on 3/3/22. At the time of the on-site visit, the agency was in substantial compliance with 42 CFR Part 484, Requirements for Home Health Agencies. The census was 116 at the time of the on-site visit. The following deficiency was cited:

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 home visit observation, clinical record review and staff interview, it was determined that the agency failed to ensure that patient medication profiles were updated to reflect current medications at the time of the comprehensive assessment for four of five patients (P) during home visits conducted by the surveyor (P#1, P#2, P#4 and P#5). The findings include: 1.A home visit was conducted at 2:00 p.m. on 3/1/22, at the residence of Patient #1 with Occupational Therapist (OT) #BB. P#1 was admitted to the home health agency on 12/10/21, with the diagnosis of hypertensive heart disease and chronic kidney disease with heart failure. The clinical record was reviewed for certification period 2/8/22 to 4/8/22. During the home visit the surveyor compared P#1's current medication list in the agency's electronic medical record (EMR) to the medications present in P#1's home. P#1 had the following medications in the home but not stated she was no longer taking them:Combigan Ophthalmic eyedrops, which are used to treat glaucomaMoxifloxacin HCl Ophthalmic eyedrops, which are used to treat eye infectionsPrednisolone Acetate Ophthalmic eyedrops, which are used to treat eye inflammationFamotidine, which is used to treat gastric reflux. P#1 also had a bottle of Carvedilol 6.25 mg (milligram) tablets in the home with directions to take twice daily. However, the medication was listed in the agency EMR as “Carvedilol 3.125 mg tabs twice a day with meals”. Carvedilol is a medication used to treat hypertension. While reviewing medications in the home with OT #BB, OT #BB verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. 2. A home visit was conducted at 12:45 p.m. on 3/1/22, at the residence of Patient #2 with Registered Nurse (RN) #AA. The patient was admitted to the home health agency on 4/13/21, with the diagnosis of encounter for attention to other artificial openings of urinary tract. The clinical record was reviewed for certification period 2/7/22 to 4/7/22. During the home visit the surveyor compared P#2’s current medication list in the agency’s EMR to the medications present in P#2’s home. P#2 had the following medications in the home but not listed in the agency EMR:Rhopressa Ophthalmic eyedrops, which are used to treat glaucomaKeflex, which is an antibiotic used to treat infectionVitamin D3, which is a nutritional supplement. P#2 also stated she was no longer taking Combigan Ophthalmic eyedrops, which are used to treat glaucoma. P#2 stated she had not been using the eyedrops “for a while” but could not remember when medication had been discontinued by per physician. However, the medication was listed in the agency EMR. Additionally, the agency had the following medication listed incorrectly in the EMR for P#2: “Cymbalta oral 30 mg, 1 cap (capsule) daily”. However, the instructions on the prescription bottle in the home instructed P#2 to take 3 capsules daily. Cymbalta is a medication used to treat depression and/ or neuropathic pain. While reviewing medications in the home with RN #AA, RN #AA verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. 3. A home visit was conducted at 10:20 a.m. on 3/2/22, at the residence of Patient #4 with RN #DD. The patient was admitted to the home health agency on 11/1/21, with the diagnosis of hypertensive heart disease without heart failure. The clinical record was reviewed for the certification period 3/1/22 to 4/29/22. During the home visit the surveyor compared P#4’s current medication list in the agency’s EMR to the medications present in P#4’s home. P#4 had the following medication listed incorrectly in the agency EMR:“Colace oral 100 mg 1 cap daily”. The primary caregiver in the home reported that P#4 was taking the medication “twice a day, but only when (P#2) needs it”. Colace is a medication used to make stool soft. While reviewing medications in the home with RN #DD, RN #DD verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. 4. A home visit was conducted at 12:00 p.m. on 3/22/22, at the residence of Patient #5 with Physical Therapy Assistant (PTA) #CC. The patient was admitted to the home health agency on 2/12/22, with the diagnosis of left knee arthroplasty. The clinical record was reviewed for the certification period 2/12/22 to 4/12/22. During the home visit the surveyor compared P#5’s current medication list in the agency’s EMR to the medications present in P#5’s home. P#6 had the following medication in the home but not listed in the agency EMR: Tylenol #3, which is a medication used to treat pain. Cetirizine, which is a medication used to treat allergies While reviewing medications in the home with PTA #CC, PTA #CC verbalized understanding of the requirement to reconcile all medications in the home with medications listed in the agency EMR during every comprehensive visit. During interview at the agency at 10:00 a.m. on 3/3/22, the Administrator was made aware that the medication profile was not updated to reflect current medications at the time of the comprehensive assessment for four of six home visits conducted during the survey (P#1, P#2, P#4 and P#5).