Every finding on record at Tuality Home Health

An unannounced Federal recertification survey was completed at this agency on 7/29/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.An entrance conference was held with the Director and Clinical Manager at 9:40 AM. The purpose of the survey and the survey needs were explained. An opportunity was provided for questions, answers and comments.Definitions and abbreviations: CFR - Code of Federal Regulations MG - miligram SOC - Start of Care

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 interview and record review, it was determined the agency failed to perform a complete review of medications that included checking medication allergies for 2 of 17 patient records reviewed (Patients #11 and #14). Findings: Review of Patient #11's record revealed a SOC date of 6/30/22. The document titled "Home Health Certification and Plan of Care" with the certification period 6/30/2022 through 8/28/2022 revealed "Allergies: Aspirin, Ace inhibitors, lisinopril, gabapentin, acetaminophen." Review of documentation of "Active Orders" dated 07/19/2022 revealed Patient #11's current medications included "Gabapentin By Mouth Capsule 100 MG 1 Capsule three times a day Oral pain Start Date: 06-30-2022." The above documentation indicated that Patient 11's allergies list had gabapentin as one of the medications Patient 11 was allergic to but the "Active Orders" indicated that Patient #11 was taking gabapentin. During an interview with Employee #1 and Employee #2 on 7/27/2022 at 2:13 PM, Employee #1 and Employee #2 verified the findings. Employee #2 stated "I don't see it addressed. It should have been caught in the medication review or reconciliation." Review of Patient #14's record revealed a SOC date of 2/19/2021. The document titled "Home Health Certification and Plan of Care" with the certification period 6/14/2022 through 8/12/2022 revealed "Allergies: suspected allergy to oxycodone-rash." Review of documentation of "Active Orders" dated 07/19/2022 revealed Patient #14's current medication included "oxyCODONE HCL By Mouth Tablet 5 MG 1 Tablet every 6 hours Oral as needed for severe pain. Start Date: 02-19-2021." During an interview with Employee #1 and Employee #2 on 7/27/2022 at 2:40 PM, Employee #1 and Employee #2 verified the findings. Employee #2 stated "Patient has been on the medication for a long time."

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 interview and medical record review, it was determined the agency failed to include: 1. A description of the patient's risk for emergency department visits and hospital re-admission on the care plan for 17 (Patients #1-17) patient care plans reviewed and; 2. Information related to any advanced directives on the care plan for 11 (Patients #1, #4-7, #9-12, #15, #16) of 17 patient care plans. Findings: 1. Review of the "Home Health Certification and Plan of Care" for Patients #1-17 revealed documentation failed to include a description of the patient's risk for emergency department visits and hospital re-admission. During an interview with Employee #1 and Employee #2 on 7/27/2022 at 2:28 PM, the above findings were presented. They acknowledged the findings and Employee #1 stated "Report we get from MyAbility shows each patient and the risk for hospitalization but nobody transfers that to the care plan." Employee #2 sent this surveyor an email on 7/27/2022 that "I have added this line to our Care Plan under Admission orders and will implement this going forward with patients we have on service currently." 2. Review of the "Home Health Certification And Plan of Care" for Patients #1, #4, #5, #6, #7, #10, #12, #15, and #16 revealed under "Advanced Directives (Types): Not in ePIC." 3. Review of the "Home Health Certification And Plan of Care" for Patients #9 and #11 revealed no information related to advanced directives were recorded. During an interview with Employee #1 on 7/28/2022 at 2:00 PM, the above findings were presented. Employee #1 stated "I guess I had already assumed that this [the advanced directive information] was on the 485 [care plan]".