Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 1/29/2024, Nason Hospital Home Health Agency was found not to be in compliance with the following requirement of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.
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, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to address significant side effects, drug interactions for two (2) of thirteen (13) MR's reviews conducted (MR7 and MR10).
Findings Included:
Review of agency policy and procedures on 1/26/2024 at approximately 1:00 PM revealed, "Medication Reconciliation Tip Sheet, Home health and hospice employees will use this tip sheet to ensure compliance with the Medication Reconciliation process throughout the patient's episode of care. For easier on-the-go reference, print document using one-page front and back. MEDICATIONO RECONCILIATION PROCESS...Verify scheduled medications have an indication for use within the medical record. It does not have to be within the order. It may be on the H&;P, hospice discharge summary, etc. Make note of ANY of the following: *Potential adverse effects/drug reactions *Ineffective drug therapy *Side effects *Drug Interactions (Note: all Level 1 &; Level 2 interactions MUST be reported to the Provider) *High Risk Drugs *You MUST provide and document that education has been given to the patient/Caregiver on All high-risk medications as "high risk" on the medication sheet *Duplicate drug therapy *Noncompliance *Dosing errors *Drug instabilities *Notify the Provider of ALL issues/discrepancies found. Documentation needs to reflect that the issue(s) and/or discrepancies were discussed. Be Specific and list the medications in question. MEDICATION RECONCILIATION-ROLES &; RESPONSIBILITIES For patients receiving Skilled Services: *The therapist is responsible for medication reconciliation. *The therapist will collaborate with team leader to complete the process."
MR7 chart review was conducted on 1/25/2024 at approximately 1:15 PM, a review of the plan of care listed the start of care 10/19/2023 for a current certification period starting 12/18/2023 to 2/15/2024. The primary diagnosis was hypertensive health disease with heart failure. The agencies "Client Medication Report" list "Client Allergies ADHESIVE TAPE, AMOXICILLIN, LISINOPRIL." Review of the patient authorizations document revealed "ALLERGIES...AMOXICILLIN Origin: 2022-10-18 Verified: 2022-10-18, DICYCLOMINE Origin: 2020-11-13 Verified: 2020-11-13, LISINOPRIL Origin: 2019-04-26 Verified: 2019-04-26..."The following allergy was not listed on the agency client medication report: DICYCLOMINE.
MR10 chart review was conducted on 1/26/2024 at approximately 9:50 AM, a review of the plan of care listed the start of care 6/20/2023 for a current certification period starting 12/18/2023 to 2/15/2024. The primary diagnosis was hypertensive health disease with heart failure. The agencies "Client Medication Report" list "Client Allergies DEMEROL, QUESTRAN, STRAWBERRIES, SULFA WELLBUTRIN..." Review of the history and physical document within the MR listed "...Allergies: Allergies allergen Demerol [Meperidine] Reactions Low BP Other (see comments) *Rocephin [Ceftriaxone] Rash..." The following allergy was not listed on the agency client medication report: Rocephin.
An exit interview was conducted with the administrator 1/29/2024 at approximately 2:00 PM which confirmed the above findings.
Plan of Correction:Immediate action implemented to correct specific deficiency
The Executive Director, on 03/5/24 entered an occurrence report related to incorrect patient allergies for patient MR #7 and MR #10.
The Executive Director verified with the physician and patient current allergies and a supplemental order was completed on 2/12/24 to update the record to reflect patient's allergy to Dicyclomine for patient MR #7 and on 2/13/24 for Rocephin for patient MR #10.
On 03/6/24 the Executive Director during an all-staff meeting, educated staff on policy 10.008 Monitoring Medications, with emphasis on ensuring allergies are correct.
ED will provide individual education to those staff unable to attend the mandatory staff meeting by 3/8/24.
New process that will be implemented to prevent deficiency from re-occurring
A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode.
The drug regimen review will include review of drug allergies to ensure these are accurate.
The clinician completing the comprehensive assessment will review referral documents and validate all allergies listed are accurate.
The physician is contacted immediately if any discrepancies are found.
Title of person responsible for implementing plan of correction
Executive Director
Date of completion
03/08/24
Monitoring procedures to ensure effectiveness of process improvement and continued compliance
Beginning on, 03/10/2024, the Executive Director will review 4 medical records per week to ensure all allergies are reflected correctly on the plan of care and any discrepancies were reconciled with the physician.
Monitoring will continue for 12 weeks and until 100% compliant for 4 consecutive weeks.
Initial Comments:Based on the findings of an onsite unannounced Medicare recertification and state relicensure survey completed 1/29/2024, Nason Hospital Home Health Agency 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 state relicensure survey completed 1/29/2024, Nason Hospital Home Health Agency 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, job description, 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 two (2) of thirteen (13) MR's reviews conducted (MR7 and MR10).
Findings Included:
Review of agency policy and procedures on 1/26/2024 at approximately 1:00 PM revealed, "Medication Reconciliation Tip Sheet, Home health and hospice employees will use this tip sheet to ensure compliance with the Medication Reconciliation process throughout the patient's episode of care. For easier on-the-go reference, print document using one-page front and back. MEDICATIONO RECONCILIATION PROCESS...Verify scheduled medications have an indication for use within the medical record. It does not have to be within the order. It may be on the H&;P, hospice discharge summary, etc. Make note of ANY of the following: *Potential adverse effects/drug reactions *Ineffective drug therapy *Side effects *Drug Interactions (Note: all Level 1 &; Level 2 interactions MUST be reported to the Provider) *High Risk Drugs *You MUST provide and document that education has been given to the patient/Caregiver on All high-risk medications as "high risk" on the medication sheet *Duplicate drug therapy *Noncompliance *Dosing errors *Drug instabilities *Notify the Provider of ALL issues/discrepancies found. Documentation needs to reflect that the issue(s) and/or discrepancies were discussed. Be Specific and list the medications in question. MEDICATION RECONCILIATION-ROLES &; RESPONSIBILITIES For patients receiving Skilled Services: *The therapist is responsible for medication reconciliation. *The therapist will collaborate with team leader to complete the process."
MR7 chart review was conducted on 1/25/2024 at approximately 1:15 PM, a review of the plan of care listed the start of care 10/19/2023 for a current certification period starting 12/18/2023 to 2/15/2024. The primary diagnosis was hypertensive health disease with heart failure. The agencies "Client Medication Report" list "Client Allergies ADHESIVE TAPE, AMOXICILLIN, LISINOPRIL." Review of the patient authorizations document revealed "ALLERGIES...AMOXICILLIN Origin: 2022-10-18 Verified: 2022-10-18, DICYCLOMINE Origin: 2020-11-13 Verified: 2020-11-13, LISINOPRIL Origin: 2019-04-26 Verified: 2019-04-26..."The following allergy was not listed on the agency client medication report: DICYCLOMINE.
MR10 chart review was conducted on 1/26/2024 at approximately 9:50 AM, a review of the plan of care listed the start of care 6/20/2023 for a current certification period starting 12/18/2023 to 2/15/2024. The primary diagnosis was hypertensive health disease with heart failure. The agencies "Client Medication Report" list "Client Allergies DEMEROL, QUESTRAN, STRAWBERRIES, SULFA WELLBUTRIN..." Review of the history and physical document within the MR listed "...Allergies: Allergies allergen Demerol [Meperidine] Reactions Low BP Other (see comments) *Rocephin [Ceftriaxone] Rash..." The following allergy was not listed on the agency client medication report: Rocephin.
An exit interview was conducted with the administrator 1/29/2024 at approximately 2:00 PM which confirmed the above findings.
Plan of Correction:Immediate action implemented to correct specific deficiency
The Executive Director, on 03/5/24 entered an occurrence report related to incorrect patient allergies for patient MR #7 and MR #10.
The Executive Director verified with the physician and patient current allergies and a supplemental order was completed on 2/12/24 to update the record to reflect patient's allergy to Dicyclomine for patient MR #7 and on 2/13/24 for Rocephin for patient MR #10.
On 03/6/24 the Executive Director during an all-staff meeting, educated staff on policy 10.008 Monitoring Medications, with emphasis on ensuring allergies are correct.
ED will provide individual education to those staff unable to attend the mandatory staff meeting by 3/8/24.
New process that will be implemented to prevent deficiency from re-occurring
A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode.
The drug regimen review will include review of drug allergies to ensure these are accurate.
The clinician completing the comprehensive assessment will review referral documents and validate all allergies listed are accurate.
The physician is contacted immediately if any discrepancies are found.
Title of person responsible for implementing plan of correction
Executive Director
Date of completion
03/08/24
Monitoring procedures to ensure effectiveness of process improvement and continued compliance
Beginning on, 03/10/2024, the Executive Director will review 4 medical records per week to ensure all allergies are reflected correctly on the plan of care and any discrepancies were reconciled with the physician.
Monitoring will continue for 12 weeks and until 100% compliant for 4 consecutive weeks.
Initial Comments:Based on the findings of an onsite unannounced State relicensure survey completed 1/29/2024, Nason Hospital Home Health Agency 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 1/29/2024, Nason Hospital Home Health Agency was found to be in compliance with the requirements of 35 P.S. § 448.809 (b).
Plan of Correction:
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