Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017016 (X3) Date Survey Completed 06/16/2022
Name of Provider or Supplier Southeast Alabama Homecare, Llc Street Address, City, State 804 Glover Avenue, Enterprise, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0536 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 observations, review of medical records (MR), agency policy, and interviews, it was determined the agency failed to ensure staff reconciled medications in 3 of 5 Home Visits (HV) conducted, including HV # 4, HV # 2 and HV # 5, and had the potential to negatively affect all patients receiving services by this agency.



Findings include:



Agency Policy: Monitoring Medications



Policy Number: 10.008



Revised Date: 5/1/19



Purpose: To provide process to ensure continuous monitoring of medications in the patient's home.



Policy:

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.



For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues...to the Patient Care Manager.


3. HV # 5 was admitted on 5/17/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4 Unspecified Chronic Kidney Disease; Heart Failure, Unspecified.




Review of the HHC and POC dated 5/17/22 revealed an order for SN 1wk9; Physical Therapist (PT) 1wk1, 2wk1,1wk1, 2wk2 1wk4; Occupational Therapist (OT) 1wk1,2wk2,1wk2; Home Health Aide (HHA) Effective 5/22/22 1wk4.




A HV was conducted on 6/15/22 at 9:15 AM with EI # 6, HHA (Home Health Aide) to observe shower assistance provided. EI # 1 Executive Director was also present.




During the HV, the CMR printed by the agency on 6/14/22 at 10:12 AM and the medications in the home were compared to the CMR and the following discrepancy was found and verified by the patient.




Benadryl 25 mg tablets one every six hours as needed was found in the home and not listed on the CMR. The patient stated," I only take that if I get into the car which is when I have a doctor's visit. I get car sick and I will vomit in my son's car if I don't take that."




An interview was conducted on 6/15/22 at 10:05 AM with EI # 1 who confirmed the staff failed to reconcile the medication per the agency policy.

1. HV # 4 was admitted to the agency on 5/11/22 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Polyneuropathy, Hypertensive Heart Disease with Heart Failure and Acute Embolism and Thrombosis of Unspecified Deep Veins of Left Lower Extremity.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 5/11/22 to 7/9/22 revealed a Skilled Nurse (SN) frequency of once a week for 1 week (1wk1), twice a week for 1 week (2wk1) then once a week for 7 weeks (1wk7).



A HV was conducted on 6/14/22 at 8:45 AM with Employee Identifier (EI) # 4, Licensed Practical Nurse, to observe wound care provided.




During the HV the agency Client Medication Report (CMR), printed by the agency on 6/14/22 at 4:03 PM, and the medications in home were compared with the following discrepancies found and verified by the patient's caregiver.




Vitamin D3 125 mcg (micrograms) 1 tablet daily was found in the home. The caregiver verbalized the patient has taken the Vitamin D3 since discharge from the hospital on 5/10/22. There was no documentation of the Vitamin D3 on the agency CMR.




Magnesium 400 mg (milligrams) 1 tablet daily. The caregiver verbalized the patient has taken the Magnesium for "a month". There was no documentation of the Magnesium on the agency CMR.




Albuterol 90 mcg 1 inhalation every 6 hours as needed was found in the home with the prescription box dated 5/17/22. There was no documentation of the Albuterol on the agency CMR.




Hydrocodone 5 mg - Acetaminophen 325 mg 1 tablet every 6 hours as need for pain was found in the home with the prescription dated 5/17/22 and verified as current by the caregiver. Review of the agency CMR revealed documentation of Hydrocodone 5 mg - Acetaminophen 325 mg 1 tablet every 4 hours as needed for pain.




Hydrocodone 7.5 mg - Acetaminophen 325 mg 1 tablet every 4 hours as needed for pain was documented on the agency CMR. The caregiver verbalized the patient had not been on Hydrocodone 7.5 mg - Acetaminophen 325 mg since "before January..."




Ipratropium 0.5 mg - Albuterol 3 mg/ 3 ml (milliliter) nebulization 3 ml 4 times daily as needed for shortness of breath was documented on the agency CMR. The caregiver verbalized the patient had not been on Ipratropium-Albuterol since discharge from the hospital on 5/10/22.




Pregabalin 1000 mg 1 capsule twice a day was found in home with prescription dated 5/16/22 and verified as current by the caregiver. Review of the agency CMR revealed documentation of Pregabalin 50 mg 1 capsule twice a day.




Triamcinolone Acetonide 0.1 % Topical Cream 1 application to the left leg twice daily was on the agency CMR. The caregiver verbalized the Triamcinolone Acetonide had been discontinued "a couple weeks."




An interview was conducted on 6/16/22 at 2:17 PM with EI # 2, Patient Care Manager (PCM), who confirmed the SN failed to reconcile medications in home per the agency policy.




2. HV # 2 was admitted to the agency on 5/16/22 with diagnoses including Encounter for Surgical Aftercare Following Surgery on the Circulatory System, Atherosclerotic Heart Disease of Native Coronary Artery with Unspecified Angina Pectoris and Essential (Primary) Hypertension.




Review of the HHC and POC dated 5/16/22 to 7/14/22 revealed a SN frequency of 2wk1 then 1wk8 and a Occupational Therapy frequency of 1wk1, 2wk2 then 1wk2.



A HV was conducted on 6/14/22 at 1:00 PM with EI # 5, Occupational Therapist, to observe care provided.




During the HV the agency CMR, printed by the agency on 6/14/22 at 10:14 AM, and the medications in home were compared with the following discrepancies found and verified by the patient.




Lantus Solostar Insulin 100 Unit/ml 6 Units Subcutaneous at bedtime was found in the home and confirmed as the current dosage by the patient "since I've been home from the hospital" on 5/15/22. Review of the agency CMR revealed documentation of Lantus Solostar dosage as 10 Units at bedtime.




Janumet XR (extended release) 50 mg/ 1000 mg 1 tablet twice daily was found in the home with prescription dated 4/6/22 and verified as current by the patient. There was no documentation of Janumet on the agency CMR.




Metformin 500 mg 1 tablet twice daily was documented on the agency CMR. The patient verbalized Metformin was discontinued "at least 5 to 6 months ago."




Tramadol 50 mg 1 tablet every 6 hours as needed for pain was documented on the agency CMR. The patient verbalized Tramadol was "gone 2 weeks ago and not in the home."





An interview was conducted on 6/16/22 at 1:48 PM with EI # 1, Executive Director, who confirmed the SN failed to reconcile medications in home per the agency policy.