Every finding on record at Suwannee Medical Personnel

An unannounced recertification survey was conducted on April 3, 2024 through April 4, 2024, at Suwannee Medical Personnel. The facility was not in compliance with 42, CFR 424.22 Requirements for Home Health Services.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure physicians' orders were followed for 2 of 2 home visit patients, Patients #1 and #2. Findings include: Review of the Medication Profile for Patient #2 documented medications to include venlafaxine 75 mg capsule extended release, 2 capsules twice a day and Entresto 24 mg-26 mg 1 tablet twice a day. During an observation on 04/03/2024 at approximately 11:10 AM Staff K, Registered Nurse (RN) gathered Patient #2’s medications to fill the medication organizer, “pill box.” Venlafaxine and Entresto were not observed to be added to the pill box. During an interview on 04/03/2024 at approximately 11:15 AM Staff K, RN said she did not know about the venlafaxine and that she thought the patient was not on Entresto anymore. Review of Patient #2’s medication record did not contain documentation of venlafaxine or Entresto being discontinued. Review of the Medication Profile for Patient #1 documented medications to include escitalopram 5 mg once daily, lisinopril 20 mg once daily, and tamsulosin 0.4 mg nightly. During an observation on 04/03/2024 at 12:30 PM Staff K, RN gathered Patient #1’s medications to fill the medication organizer, “pill box.” Escitalopram 5 mg, lisinopril 20 mg, and tamsulosin 0.4 mg were not observed to be added to the pill box. During an interview on 04/03/2024 at approximately 12:42 PM Staff K, RN stated the escitalopram was not put in the pill box because the patient’s wife does not want it given. The lisinopril was not put in the pill box because it was discontinued March 22, 2024. For the tamsulosin the nurse said she didn’t know about that medication. Review of Patient #1’s medical record did not contain a physician’s order to discontinue the lisinopril, escitalopram or the tamsulosin. There was no documentation in the record of the physician being notified of the patient not being administered these medications or the patient’s spouse not wanting escitalopram administered. Review of the policy and procedure titled, “Patient Assessment and Plan of Care" read, "Changes to the Plan of Care: The physician is notified in a timely and appropriate manner of any changes in the patient’s clinical status and/or needs or requests that suggest a need to modify the plan of care. Changes to the plan of care based on patient requests, changes in the patient’s clinical status, the patient’s response to therapy and/or physician orders, are documented in the patient’s medical record within the visit notes with documentation that the physician is aware of changes, and/or as verbal-telephone physician orders. Review of the policy and procedure titled, “Medication Profile and Review” read, “Purpose: To obtain and maintain a comprehensive and concise record of all the medications a patient is taking. Policy: The licensed nurse is responsible for reviewing and evaluation all the patient’s medications on admission and on an ongoing basis. Procedure: When medications are discontinued, the discontinued date is documented in the Medicine Schedule. Medication Assessment: Checking the prescribed medications for the correct dosage and frequency. Any discrepancies must be clarified with the ordering physician and/or the pharmacist.