Every finding on record at Pioneer Home Health Care, Inc

Based on interview and record review, the agency failed to ensure patient medications were being reviewed in accordance with the agencys policy, for one of 14 sampled patients (Patient 1), when five of Patient 1s discontinued medications were listed on his current Medication Profile (MP-a current list of all medications prescribed to a patient). This failure had the potential to cause ineffective drug therapy, significant side effects, and noncompliance with drug therapy to Patient 1, placing his health at risk. Findings: A review of the Patient 1s Plan of Care (POC) with a certification period of August 13, 2023, to September 12, 2023, indicated Patient 1 had diagnosis that included Alzheimers (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life.). Patient 6 had a start of care date of December 15, 2022. During a home visit on August 16, 2023, with Registered Nurse Case Manager (RNCM), and in the presence of Patient 1 and Patient 1s son, Patient 1s actual medication bottles, which were available in the home, were compared with Patient 1s most current Medication Profile (MP). During a concurrent observation and interview on August 16, 2021, at 10:40 AM, with RNCM, RNCM stated, ";Patient 1 stopped taking Amlodipine (high blood pressure medication) 5 mg (milligram-a unit of measure) tablet, Aspirin (over the counter medication used to lower risk of heart attack) 81 mg tablet, Benazepril (high blood pressure medication) 20 mg tablet, Hydrochlorothiazide (a water pill that helps to lower blood pressure and ease swelling from fluid) 12.5 mg tablet, and Klor-Con 10 (potassium chloride supplement used to treat and prevent low potassium levels in the blood) 10 mEq (milliequivalent-a unit of measure) tablet 2 weeks ago. RNCM stated the printed MP should have been updated." During a follow up interview with RNCM, on August 16, 2023, at 11:45 AM, RNCM stated, ";I am aware the patient [Patient 1] stopped taking Amlodipine, Aspirin, Benazepril, Hydrochlorothiazide and Klor-Con 10, I updated manually the home MP, I just been busy and dont have time to updated on the system. Its my responsibility to update." During an interview on August 17, 2023, at 11:15 AM, with Administrator/Director of Patient Care Services (Admin/DPCS), Admin/DPCS stated, ";It was Case Manager's responsibility to update Medication Profile when there's any new order or changes. Nurses should have been reviewing and updating medication profile on their visits." A review of the agencys policy and procedure titled ";Medication Administration: Medication Reconciliation," revised July 17, 2023, indicated, ";Purpose: To promote medication safely through processes to compare current medication order with what medication patients are actually taking. Consideration: ... 4. Hospice nurses are responsible for developing a current list of medication, assuring the patient has a current list... 8. Medication should be also be reviewed at every nursing Re-visit for accuracy and further education. Procedure... e. Carefully compare the medication list you have created from the drugs in the patients home to the medication list supplies by discharging facility or by the physician. f. Identified any discrepancy between list... g. ...report and resolve the discrepancies with the physician within one da. h. Amend the medication profile as per physician orders..."