Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 2/14/2024, Cambria Home Health Inc. was found not to be in compliance with the following requirement of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart G, Chapter 601, Home Health Care Agencies.
Plan of Correction:
601.31(d) REQUIREMENT
CONFORMANCE WITH PHYSICIAN'S ORDERS
Name - Component - 00
601.31(d) Conformance With
Physician's Orders. All prescription
and nonprescription (over-the-counter)
drugs, devices, medications and
treatments, shall be administered by
agency staff in accordance with the
written orders of the physician.
Prescription drugs and devices shall
be prescribed by a licensed physician.
Only licensed pharmacists shall
dispense drugs and devices. Licensed
physicians may dispense drugs and
devices to the patients who are in
their care. The licensed nurse or
other individual, who is authorized by
appropriate statutes and the State
Boards in the Bureau of Professional
and Occupational Affairs, shall
immediately record and sign oral
orders and within 7 days obtain the
physician's counter-signature. Agency
staff shall check all medicines a
patient may be taking to identify
possible ineffective drug therapy or
adverse reactions, significant side
effects, drug allergies, and
contraindicated medication, and shall
promptly report any problems to the
physician.
Observations:
Based on a review of agency policy and procedure, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to identify medication potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions for one (1) of three (3) MR ' s reviews conducted (MR1).
Findings Included:
Review of agency policy and procedures on 2/14/2024 at approximately 10:00 revealed, " Medication Reconciliation POLICY, The Agency will reconcile patient ' s medications at time of admission and on an ongoing basis in order to identify and potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy ...PROCEDURE 1. At time of admission, the admitting RN, PT, or SLP will create and document a complete list of medications that patient is taking at home, including dose, strength, route, and frequency. * Any concerns or discrepancies will be reconciled by a RN with the patient ' s physician/practitioner ...2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient medication list in the home will also be updated ... "
MR1 chart review was conducted on 2/12/2024 at approximately 1:20 PM, a review of the plan of care listed the start of care 7/1/2012 for a current certification period starting 12/21/2023 to 2/18/2024. The primary diagnosis was profound intellectual disability. The agencies " HOME HEALTH CERTIFICATION AND PLAN OF CARE " listed " 17. Allergies: codine ... " Two documents reviewed within MR1 revealed a visit summary dated " 12/12/2023 ...Allergies Codeine, reaction: Hives, Swelling, fever, Cyproheptadine, Reaction: Hives, Swelling fever ... " The second document listed revealed " INDIVIDUAL SUPPORT PLAN ...Allergies, Known Allergy: CODEINE ...Known Allergy: CYPROHEPTADINE (CYPROHEPT, PERIACTIN) ... "
The following allergy was not listed on the agency medication profile: Cyproheptadine.
An exit interview was conducted with the administrator on 2/14/2024 at approximately 11:30 AM which confirmed the above findings.
Plan of Correction:PCP was notified of missing allergy on client's (MR1) CMS485 and medication profile sheets. CMS 485, medication records and client's information sheet were updated to reflect the missing allergy in the client's office and home charts.
A mandatory in-service provided to all professional clinicians on "Allergies and Documentation" and review of the agency "Medication profile Policy" presented by the Administrator.
Staff will be assessing and addressing all patient allergies on a ongoing basis based on patient assessment, physician records and referral source records; if discrepancies are found will call physician, and make sure that it is reflected on the agency patient medication record and plan of treatment.
RN/Admin (CL) will review client's charts with every recertification to ensure all information is current and correct.
All documentation will be reviewed with every new admission and with quarterly chart review to ensure all allergies are listed appropriately in the client's chart. If discrepancies are found will call physician, and make sure that it is reflected on the agency patient medication record and plan of treatment.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 2/14/2024, Cambria Home Health Inc. was found to be in compliance with the requirements of PA Code, Title 28, Health and Safety, Part IV, Health Facilities, Subpart A, Chapter 51.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey completed 2/14/2024, Cambria Home Health Inc. was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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