| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017024 | (X3) Date Survey Completed 10/21/2021 |
| Name of Provider or Supplier Southeast Alabama Homecare, Llc | Street Address, City, State 3813 Ross Clark Circle, Suite 300, Dothan, 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 review of agency policy and procedure, observations, medical record (MR) review and interviews with the staff, it was determined the agency failed to ensure staff updated and maintained an accurate medication profile for each patient per the agency policy. This affected 4 of 6 Home Visits (HV), including HV # 6, # 3, HV # 2, HV # 5, and had the potential to affect all patients served by the agency. Findings include: Agency policy: Monitoring Medications Policy Number: 10.008 Revised Date: 5/1/19 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 issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode. Procedure: 1. The discipline responsible for the drug regimen review will: a. Compare medication list obtained from the facility from which the patient was transferred and/or physician order to actual medications patient is taking. b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams, and topical ointments. 2. All clinicians participating in their patient’s care are responsible to assist with the maintenance of accurate patient medication information throughout their episode of care. a. Through a collaborative process the care team will: i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies. 4. HV # 5 was admitted to the agency on 1/4/2019 with diagnosis including Neuromuscular Dysfunction of Bladder, Unspecified and Encounter for Attention to Cystostomy. A HV was conducted 10/19/21 at 11:10 AM with EI # 8, Home Health Aide, to observe care provided. The surveyor was accompanied on the HV by EI # 6, RN. During the visit, the medications in the home were compared to the current MP provided by the agency and the following discrepancies were found and verified by the patient and EI # 6 RN: a. Calcium Carb-Vit (Vitamin) D3-Minerals 600 mg, 200 unit tablet, dose one tablet daily listed on the MP but per the patient, was discontinued about one year ago. b. Collagen Plus Vitamin C 125 mg - 740 mg capsule, dose three capsules daily listed on the MP but per the patient, was discontinued about one year ago. c. Cranberry Concentrate 500 mg capsule, dose 1 capsule daily listed on the MP but per the patient, was discontinued about one year ago. d. Evista 60 mg tablet, dose 1 tablet daily listed on the MP but per the patient, was discontinued about one year ago. e. Advil 200 mg tablets found in the home but not on the MP. Per the patient, takes two tablets daily as needed for about a year. f. BHI Diarrhea tablets found in the home but not on the MP. Directions on the bottle state one tablet every 4 to 6 hours as needed. Per the patient takes two tablets after the second loose stool as needed and has taken this medication, for "a long time". EI # 6 confirmed during the home visit the MP was not accurate. 3. HV # 2 was admitted to the agency 9/17/21 with a diagnosis of Unspecified Rotator Cuff Tear/Rupture of Left Shoulder-Not Trauma. A home visit was conducted 10/19/21 at 12:00 PM with EI # 3, Occupational Therapist, to observe treatment provided to the patient and medication reconciliation. The medications in the home were compared to the current MP provided by the agency and the following discrepancies were found. The medications were in the home and not on the Medication Profile and verified by the patient and wife: a. Sotalol HCL (Hydrochloride) 80 mg one by mouth daily-wife states has been on this medication for at least one year. b. Magnesium Oxide 400 mg by mouth Bid (twice) states has been on this medication since April 2021. c. Bumetanide 2 mg by mouth daily PRN (as needed) Has been taking since April 2021. d. Spironolactone 25 mg by mouth daily. Has been taking since April 2021. e. Senna 8.6 mg 1 by mouth daily PRN. Has been taking since September 7, 2021 f. Tylenol Extra Strength 1 tablet, 500 mg every 4 to 6 hours PRN. Has been taking for a couple weeks per wife. The following medication was on the Medication Profile and the patient’s wife stated he quit taking 6 months ago: Furosemide 40 mg 1 tablet by mouth daily. An interview was conducted on 10/21/21 at 11:00 AM with EI # 1 who confirmed the Medication Profile should have been verified and updated. 2. HV # 3 was admitted on 9/22/21 with diagnoses including Urinary Tract Infection, Pseudomonas, and Unspecified Escherichia Coli. A HV was conducted on 10/20/21 at 8:32 AM to observe care provided by EI # 4, RN (Registered Nurse). The medications in the home were compared to the Medication Profile provided by the Agency and the following discrepancies were found and verified with EI # 4 and HV # 3. a. Atorvastatin 80 mg one tablet daily was listed on the Medication Profile. Instructions on the medication bottle in the home filled on 9/2/21 was for ½ tablet daily. HV # 2 confirmed he/she has been taking ½ tablet daily since the prescription change. b. Glipizide 10 mg, 2 tablets 2 times daily was listed on the Medication Profile. Instructions on the bottle filled 8/25/21 was for 1 tablet 2 times daily. HV # 3 stated he/she has been taking the 1 tablet twice a day for a month or so. In an interview conducted on 10/21/21 at 11:10 AM, EI # 1, Executive Director, confirmed the Medication Profile had not been updated per agency policy. 1. HV # 6 was admitted to the agency 9/21/21 with diagnoses including Paraplegia and Essential Hypertension. A HV was conducted 10/19/21 at 12:30 PM with Employee Identifier (EI) # 7, Licensed Practical Nurse, to observe wound care and medication reconciliation. The medications in the home were compared to the current Medication Profile (MP) provided by the agency and the following discrepancies were found and verified by the patient and EI # 7: a. Gabapentin 300 mg (milligrams) 2 times per day with a date of 8/30/21 on the bottle was in the home. The MP profile had 3 times per day. The patient stated he/she had been taking 2 a day for a "long time." b. Niacin 1000 mg OTC 1 time per day was in the home and not listed on the MP. The patient stated the doctor had put him/her on that "over a year ago for cholesterol." EI # 7 confirmed during the home visit the MP was not accurate. |