| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017027 | (X3) Date Survey Completed 05/22/2025 |
| Name of Provider or Supplier Hga Homecare, Llc | Street Address, City, State 2050 Beltline Rd Sw, Decatur, 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 medical records (MR), observations, agency policy and procedure and interviews, it was determined the agency failed to keep the medication profile current. This did affect three of seven Home visits (HV) conducted including HV # 3, HV # 5 and HV # 4, and had the potential to affect all persons served by the agency. Findings include: Agency Policy: Monitoring Medications Policy Number: 10.008 Date Revised: 7/1/2024 Purpose: To provide a 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... Procedure: 1a...Compare medication list to actual medications the patient is taking. 1b. Review all medications including over the counter (OTC) medications, vitamins, herbs and herbal products, creams and topical ointments... 3. HV # 4 was admitted for home health services on 2/24/25 with a primary diagnosis of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1-4/ Unspecified Chronic Kidney Disease. Review of physician's orders dated 5/11/25 revealed orders for the Speech Therapist (ST) to visit once a week for four weeks effective 5/11/25. A HV was conducted on 5/20/25 at 11:39 AM to observe care provided by EI # 5, ST. During the HV, HV # 4's medicine list was compared to the medications the patient was currently taking. The following discrepancy was observed: Metoprolol Succinate ER 25 mg tablet, Extended Release 24 hour-oral tablet, take one tablet two times daily was documented on the medicine list. Metoprolol Succinate ER 50 mg tablet, Extended Release 24 hour-oral tablet, take one tablet one time daily was present in the home with a filled date of 4/16/25. The dosages and amount of tablets to take did not match. An interview was conducted on 5/22/25 at 1:21 PM with EI # 2, who confirmed staff failed to follow the policy for monitoring medications. 2. HV # 5 was admitted for home health services on 3/28/25 with a primary diagnosis of Chronic Diastolic (Congestive) Heart Failure. Review of the HHC and POC for certification period 3/28/25 to 5/26/25 revealed orders for the SN to visit one time a week for nine weeks. A HV was conducted on 5/20/25 at 2:37 PM to observe care provided by EI # 4, Registered Nurse (RN). During the HV, HV # 5's medicine list was compared to the medications the patient was currently taking. The following discrepancies were observed: a. Cyclobenzaprine ER (extended release) 15 mg capsule, take one capsule three times daily was on the list. HV # 5 stated his/her physician had stopped the Cyclobenzaprine about six months ago and changed to Tizanidine, which was also on the list. b. Omeprazole 20 mg delayed release capsule, take one capsule daily, was on the list. HV # 5 stated he/she stopped taking the Omeprazole about six months ago, and began taking Protonix instead. A bottle of Protonix 40 mg, take one tablet daily, with fill date 2/13/25 was observed in the home. Protonix was not on the medicine list. An interview was conducted on 5/22/25 at 1:29 PM with EI # 2, Area Administrator, who confirmed staff failed to follow the policy for monitoring medications. 1. HV # 3 was admitted to the agency on 4/22/25 with a primary diagnosis of Wedge Compression Fracture of Unspecified Thoracic Vertebra, Subsequent Encounter for Fracture with Routine Healing. Review of the Home Health Certification (HHC) and Plan of Care (POC) for certification period 4/22/25 to 6/20/25 revealed orders for the skilled nurse (SN) to visit once a week for nine weeks. A HV was conducted on 5/20/25 at 2:30 PM to observe care provided by Employee Identifier (EI) # 3, Physical Therapist. During the HV, HV # 3's medicine list was compared to the medications the patient was currently taking. The following medications were observed in the home but not listed on the medicine list: a. Tamsulosin 0.4 milligrams (mg) tablet daily. HV # 3 reported he/she has been taking the medication for a "long time". b. Fluticasone Propionate Nasal Spray 50 micrograms 2 sprays per day as needed. HV # 3 stated he has been using it "a few weeks". An interview was conducted on 5/22/25 at 1:20 PM with EI # 1, Executive Director, who confirmed staff failed to follow the policy for monitoring medications. |