Every finding on record at Willamette Healthcare LLC

An unannounced Federal recertification survey was completed at this agency on 10/27/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484.102 Emergency Preparedness. An entrance conference was held in person with the Business Manager and over the phone with the Home Health Administrator on 10/18/2022 at 11:45 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 HHA -Home Health Agency QAPI - Quality Assurance and Performance Improvement VP - Vice President

An unannounced Federal recertification survey was completed at this agency on 10/27/2022. The agency was surveyed for compliance with 42 CFR Conditions of Participation for Home Health Agencies, Part 484. An entrance conference was held on 10/18/2022 at 11:45 AM with the Business Operations Manager and virtual with the Administrator of Home Health. 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 HCL - Hydrochloride HHA - Home Health Agency MG - Milligram PRN - “Pro Re Nata” or as needed QAPI - Quality Assurance and Performance Improvement VP - Vice President

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 orders for accuracy for 5 of 17 patient records reviewed (Patients #7, #9, #11, #14 and #17). Findings: Patient #7: Review of the document titled "Home Health Certification And Plan Of Care," with a certification period of 08/21/2022 to 10/19/2022 revealed under the section "Medications: HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET, ORAL,1 tablet 6 TIMES DAILY/PRN Reason: PAIN." The order failed to give a clear time interval on how much time in-between medication doses should pass before the next dose is taken if needed. Patient #9: Review of the document titled "Home Health Certification And Plan Of Care," with a certification period of 10/10/2022 to 12/8/2022 revealed under the section "Medications: ACETAMINOPHEN 325 MG TABLET, ORAL, 2 tablet EVERY 4 HOURS/PRN, Reason: PAIN, Instructions: TAKE 2 TABS BY MOUTH EVERY 4 HOURS PRN" and the order "HYDROXYZINE HCL 10 MG TABLET, BY MOUTH, 1-2 tablet, 3 TIMES DAILY/PRN, Reason: PURITIS." The order failed to prevent the potential to exceed the recommended 24 hour amount of Acetaminophen for adults if taken every 4 hours. The Hydroxyzine HCL order failed to give a clear time interval in-between medication doses. Patient #11: Review of the document titled "Home Health Certification And Plan Of Care," with a certification period of 8/28/2022 to 10/26/2022 revealed under the section "Medications: TYLENOL 325 MG TABLET, ORAL, 2 tablet, EVERY 6 HOURS/PRN, Reason: PAIN/FEVER" and the order "TYLENOL EXTRA STRENGTH 500 MG TABLET, ORAL, 2 tablet, 3 TIMES A WEEK, REASON: WOUNDCARE [sic] PAIN." The orders failed to prevent the potential to exceed the recommended 24 hour amount of Tylenol from all sources for adults on 3 days out of the week when taken as prescribed. Patient #14: Review of the document titled "Home Health Certification And Plan Of Care," with a certification period of 10/12/2022 to 12/10/2022 revealed under the section "Medications: ACETAMINOPHEN 325 MG TABLET, ORAL, 2 tablet, EVERY 6 HOURS/PRN, Reason: PAIN" and HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET, ORAL, 1 tablet, EVERY 4 HOURS/PRN, Reason: PAIN." The orders failed to prevent the potential to exceed the recommended amount of Acetaminophen in 24 hours from all sources for adults when taken as prescribed. Patient #17: Review of the document titled "Home Health Certification And Plan Of Care," with a certification period of 9/20/2022 to 11/18/2022 revealed under the section "Medications: TRAMADOL 50 MG TABLET, ORAL, 1 tablet, 4 TIMES DAILY/PRN, Reason: MODERATE PAIN." The order failed to give a clear time interval on how much time in-between medication doses should pass before the next dose is taken if needed. During an interview with the HHA Administrator and the Business Operations Manager on 10/27/2022 beginning at 2:30 PM via Teams, the above findings were presented. The HHA Administrator acknowledged that this was a problem that they were aware of and have been working with the ordering providers to avoid discrepancies like these.