Every finding on record at Washington Regional Medical Center

On 3/29/22 at 10:15 AM an entrance conference was conducted with Agency Representatives. The Agency was informed the purpose of the visit was to conduct a Medicare recertification survey for compliance with the Conditions of Participation for Home Health. On 4/01/22 at 9:30 AM an exit conference was conducted the Agency Representatives. Preliminary findings of the survey were discussed. The Agency was NOT in compliance. Findings as follows

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 clinical record review and staff interviews, it was determined the Skilled Nurse (SN) failed to include all medications during the review of the patient's medications in 2 (# 3, #9) of 17 (#1-#17) clinical records reviewed. This failed practice by the SN posed a risk of potential harm for all patients prescribed Oxygen by inhibiting the Nurse and Physician's ability to make informed decisions regarding the patient's medication regimen related to potential adverse effects, drug reactions, significant side effects or significant drug interactions. 1. Clinical Record #3 a) Document titled Home Health Certification and Plan of Care, Subsection "Safety Measures" revealed " O2 (Oxygen) Precautions." b) Document titled Home Health Certification and Plan of Care, Subsection "Orders and Treatments" revealed a physician's order " SN (Skilled Nurse) to monitor for compliance with Oxygen Therapy and Oxygen safety with each SNV (Skilled Nurse Visit)." c) Review of a form titled, “Medication Profile” (the form the agency uses to record the medications the patient is taking) and dated 3/19/2022 through 5/17/2022, revealed the Agency did not include oxygen as a medication the patient was taking. Staff Interview with Agency Representative #1 agreed Oxygen was omitted from Medication Profile. 2. Clinical Record #9 a) Document titled Home Health Certification and Plan of Care, Subsection "DME (Durable Medical Equipment) & Supplies" showed Oxygen listed as a patient supply. b) Document titled Home Health Certification and Plan of Care subsection "SN Interventions" Revealed "SN to monitor for compliance with Oxygen therapy and Oxygen safety each SNV (Skilled Nurse Visit)." c) Review of a form titled, “Medication Profile” (the form the agency uses to record the medications the patient is taking) and dated 3/01/2022 through 4/09/2022, revealed the Agency did not include oxygen as a medication the patient was taking. Interview with Agency Representative #1 agreed Oxygen was omitted from Medication Profile.