Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey conducted 3/8/2024 through 3/15/2024, UPMC Home Healthcare of Central Pennsylvania was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.
Plan of Correction:
Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey conducted 3/8/2024 through 3/15/2024, UPMC Home Healthcare of Central Pennsylvania was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation.
Plan of Correction:
484.55(c)(5) ELEMENT
A review of all current medications
Name - Component - 00
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.
Observations:
Based on a review of agency policy and procedure, patient observations visits (OBV), medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of all medications the patient was taking, address potential adverse effects, drug reactions, ineffective drug therapy, significant side effects and drug interactions for three (3) of seventeen (17) MR's reviewed (MR4-OBV6, MR7-OBV3, MR10).
Findings Included:
Review of agency policy and procedure on 3/13/2024 at approximately 12:45 PM revealed, "Category: M MEDICATIONS MEDICATION MANAGEMENT RECONCILIATION... Accurate and complete reconciliation of medications should occur across the continuum of care...EQUIPMENT Patient medication(s) and delivery method, Discharge summary, Agency patient Medication List, patient documentation record access (Medication Profile) PROCEDURE...4. All ordered medications must be listed accurately on a paper list and entered electronically into the medical record...9. If needed, create the Patient Medication List that includes ALL medications the patient is taking. The sources of information for the Patient Medications List should include: a. Patient pill containers, prescriptions, OTC medications, vitamins, herbal supplements, topicals, IV medications/flushes, eye drops. b. Hospital discharge list of medications, if applicable, and referral information. C. Medications listed in the electronic record from previous admissions. d. Medication lists created by the patient. e. Information elicited from patient by questioning i.e. medications they may take occasionally, or medications kept in different parts of the home...f. Information about medications taken infrequently i.e., B12, Fosamax. g. Medications not reordered following a change in the plan of care (i.e., following a hospitalization). 14.Assess the patient's allergy history. If the patient has a known or suspected allergy/adverse reaction history or sensitivity to a medication, I will not be administered. Contact the physician, PA or CRNP for further direction. (Therapy staff refer to a nurse) for assistance...17. Check for adverse interactions and notify physician, PA, or CRNP if severity Level 1 drug interaction is identified. Therapy staff refer to a nurse for assistance..."
Review of (OBV6 MR4) was conducted on 3/14/2023 at approximately 1:55 PM, a review of the plan of care listed the start of care 3/1/2024 for a current certification period starting 3/1/2024 and ending 4/29/2024. The primary diagnosis was urinary tract infection, site not specified. The agency "Medication profile" dated 3/12/2024 was compared to the facilities "PHYSICIAN'S ORDERS date printed 3/14/2024.
The following medication was not listed on the agency medication profile.
"POT CL MICRO TAB 10MEQ ER...TAKE 1 TABLET BY MOUITH ONCE DAILY...3/6/2024."
Review of (OBV3-MR7) on 3/14/2024 at approximately 10:28 AM revealed, a review of the plan of care with a start date of 1/12/2023 and a current certification period starting 1/19/2024 and ending 3/18/2024. The primary diagnosis was other complications of procedures, not elsewhere classified. The home health certification and plan of care and medication profile did not list one of two patient allergies. Allergies listed on the agency medication profile printed 3/12/2024 and the plan of care was "Lisinopril." Listed on the agency "Patient Information Facesheet... Allergies metoprolol...lisinopril"
Review of MR10 on 3/12/2024 at approximately 1:48 PM revealed, a review of the plan of care with a start date of 3/7/2023 and a current certification period starting 3/1/2024 and ending 4/29/2024. The primary diagnosis was acute tracheitis without obstruction. The home health certification and plan of care and medication profile was compared to the medical record document "Continuity of Care Document 2/26/2023." The agency documentation did not list three (3) of four (4) patient allergies. Allergies listed on the agency medication profile printed 3/11/2024 and the plan of care was "cefepime." Listed on the continuity of care document was "Allergies, Adverse Reactions, Alerts...propofol...cefepime1...Lactated Ringers Irrigation...Plasma-Lyte..."
An exit interview with the senior director of regional home health services, vice president of clinical operations, manager of quality and compliance, director of clinical operations. Via conference call the following staff joined the exit conference: president of home health and hospice, senior director of quality and compliance, director of quality and compliance, senior manager of quality and compliance, physical therapy director rehab services, occupational therapy coordinator, (two) 2 quality and compliance coordinators and (nine) 9 clinical managers on 3/15/2024 at approximately 11:55 AM confirmed the above findings.
Plan of Correction:1. The administrator reviewed the agency's Clinical Procedure Medication Management Reconciliation on 4/8/24 with no revisions necessary.
2. The Medication Profile on OBV6-MR4 was reviewed and POT CL Micro tab 10 MEQ ER take one daily was added on 3/12/24 at 1539 by agency field staff.
3. Education will be provided to the identified field staff who exhibited deviation from the Medication Management Reconciliation Procedure for OBV6-MR4 by 4/12/24.
4. Education will be provided to all agency field staff by the Clinical Managers regarding Medication Management Reconciliation by 4/26/24.
5. An on-site supervisory visit will be completed for 25% of each clinical team's visiting staff to ensure the Medication Management Reconciliation Procedure is followed by 5/10/24.
6. The agency confirmed allergies to Lisinopril and Metoprolol with the signing physician for OBV3-MR7 and an updated order was obtained. The Medication Profile on OBV3-MR7 was updated to include allergies to Lisinopril and Metoprolol.
7. The agency confirmed allergies to Propofol, Cefepime, Lactated Ringers Irrigation, and Plasma-Lyte with the signing physician for MR10, and an updated order was obtained. The Medication Profile for MR10 was updated to include allergies to Propofol, Cefepime, Lactated Ringers Irrigation, and Plasma-Lyte.
8. The agency will create a Clinical Procedure for Allergy Reconciliation by 4/22/24.
9. All agency field staff will be educated by the Clinical Managers regarding the Allergy Reconciliation Procedure by 4/26/24.
10. The agency will audit 50% of SOCs and ROCs performed between the timeframe of 4/27/24 to 5/10/24 to ensure the allergy reconciliation process is followed.
11. To ensure that the deficiencies related to allergy reconciliation do not recur, allergy accuracy will be added to the quarterly record audit tool and the in-home supervisory checklist. Performance related to medication reconciliation and allergy accuracy will be monitored through ongoing operational in-home supervisory visits and record audits.
Initial Comments:
Based on the findings of an onsite unannounced state relicensure survey conducted 3/8/2024 through 3/15/2024, UPMC Home Healthcare of Central Pennsylvania was found not to be in compliance with the 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, patient observations visits (OBV), medical record (MR) and staff (EMP) interview, agency staff failed to identify and confirm medications the patient is taking and drug allergies for three (3) of seventeen (17) MR's reviewed (MR4-OBV6, MR7-OBV3, MR10).
Findings Included:
Review of agency policy and procedure on 3/13/2024 at approximately 12:45 PM revealed, "Category: M MEDICATIONS MEDICATION MANAGEMENT RECONCILIATION... Accurate and complete reconciliation of medications should occur across the continuum of care...EQUIPMENT Patient medication(s) and delivery method, Discharge summary, Agency patient Medication List, patient documentation record access (Medication Profile) PROCEDURE...4. All ordered medications must be listed accurately on a paper list and entered electronically into the medical record...9. If needed, create the Patient Medication List that includes ALL medications the patient is taking. The sources of information for the Patient Medications List should include: a. Patient pill containers, prescriptions, OTC medications, vitamins, herbal supplements, topicals, IV medications/flushes, eye drops. b. Hospital discharge list of medications, if applicable, and referral information. C. Medications listed in the electronic record from previous admissions. d. Medication lists created by the patient. e. Information elicited from patient by questioning i.e. medications they may take occasionally, or medications kept in different parts of the home...f. Information about medications taken infrequently i.e., B12, Fosamax. g. Medications not reordered following a change in the plan of care (i.e., following a hospitalization). 14.Assess the patient's allergy history. If the patient has a known or suspected allergy/adverse reaction history or sensitivity to a medication, I will not be administered. Contact the physician, PA or CRNP for further direction. (Therapy staff refer to a nurse) for assistance...17. Check for adverse interactions and notify physician, PA, or CRNP if severity Level 1 drug interaction is identified. Therapy staff refer to a nurse for assistance..."
Review of (OBV6 MR4) was conducted on 3/14/2023 at approximately 1:55 PM, a review of the plan of care listed the start of care 3/1/2024 for a current certification period starting 3/1/2024 and ending 4/29/2024. The primary diagnosis was urinary tract infection, site not specified. The agency "Medication profile" dated 3/12/2024 was compared to the facilities "PHYSICIAN'S ORDERS date printed 3/14/2024.
The following medication was not listed on the agency medication profile.
"POT CL MICRO TAB 10MEQ ER...TAKE 1 TABLET BY MOUITH ONCE DAILY...3/6/2024."
Review of (OBV3-MR7) on 3/14/2024 at approximately 10:28 AM revealed, a review of the plan of care with a start date of 1/12/2023 and a current certification period starting 1/19/2024 and ending 3/18/2024. The primary diagnosis was other complications of procedures, not elsewhere classified. The home health certification and plan of care and medication profile did not list one of two patient allergies. Allergies listed on the agency medication profile printed 3/12/2024 and the plan of care was "Lisinopril." Listed on the agency "Patient Information Facesheet... Allergies metoprolol...lisinopril"
Review of MR10 on 3/12/2024 at approximately 1:48 PM revealed, a review of the plan of care with a start date of 3/7/2023 and a current certification period starting 3/1/2024 and ending 4/29/2024. The primary diagnosis was acute tracheitis without obstruction. The home health certification and plan of care and medication profile was compared to the medical record document "Continuity of Care Document 2/26/2023." The agency documentation did not list three (3) of four (4) patient allergies. Allergies listed on the agency medication profile printed 3/11/2024 and the plan of care was "cefepime." Listed on the continuity of care document was "Allergies, Adverse Reactions, Alerts...propofol...cefepime1...Lactated Ringers Irrigation...Plasma-Lyte..."
An exit interview with the senior director of regional home health services, vice president of clinical operations, manager of quality and compliance, director of clinical operations. Via conference call the following staff joined the exit conference: president of home health and hospice, senior director of quality and compliance, director of quality and compliance, senior manager of quality and compliance, physical therapy director rehab services, occupational therapy coordinator, (two) 2 quality and compliance coordinators and (nine) 9 clinical managers on 3/15/2024 at approximately 11:55 AM confirmed the above findings.
Plan of Correction:1. The administrator reviewed the agency's Clinical Procedure Medication Management Reconciliation on 4/8/24 with no revisions necessary.
2. The Medication Profile on OBV6-MR4 was reviewed and POT CL Micro tab 10 MEQ ER take one daily was added on 3/12/24 at 1539 by agency field staff.
3. Education will be provided to the identified field staff who exhibited deviation from the Medication Management Reconciliation Procedure for OBV6-MR4 by 4/12/24.
4. Education will be provided to all agency field staff by the Clinical Managers regarding Medication Management Reconciliation by 4/26/24.
5. An on-site supervisory visit will be completed for 25% of each clinical team's visiting staff to ensure the Medication Management Reconciliation Procedure is followed by 5/10/24.
6. The agency confirmed allergies to Lisinopril and Metoprolol with the signing physician for OBV3-MR7 and an updated order was obtained. The Medication Profile on OBV3-MR7 was updated to include allergies to Lisinopril and Metoprolol.
7. The agency confirmed allergies to Propofol, Cefepime, Lactated Ringers Irrigation, and Plasma-Lyte with the signing physician for MR10, and an updated order was obtained. The Medication Profile for MR10 was updated to include allergies to Propofol, Cefepime, Lactated Ringers Irrigation, and Plasma-Lyte.
8. The agency will create a Clinical Procedure for Allergy Reconciliation by 4/22/24.
9. All agency field staff will be educated by the Clinical Managers regarding the Allergy Reconciliation Procedure by 4/26/24.
10. The agency will audit 50% of SOCs and ROCs performed between the timeframe of 4/27/24 to 5/10/24 to ensure the allergy reconciliation process is followed.
11. To ensure that the deficiencies related to allergy reconciliation do not recur, allergy accuracy will be added to the quarterly record audit tool and the in-home supervisory checklist. Performance related to medication reconciliation and allergy accuracy will be monitored through ongoing operational in-home supervisory visits and record audits.
Initial Comments:Based on the findings of an onsite unannounced state relicense survey completed 3/15/2024, UPMC Home Healthcare of Central Pennsylvania 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 on-site unannounced State relicense survey completed 3/15/2024, UPMC Home Healthcare of Central Pennsylvania was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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