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 017037 (X3) Date Survey Completed 11/21/2019
Name of Provider or Supplier Alabama Homecare Of Montgomery, Llc Street Address, City, State 400 South Union Street Suite 285, Montgomery, 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 the policy and procedure, observations and interviews, it was determined the agency failed to ensure medication reconciliation was performed.



This deficient practice affected 5 of 17 medical records (MR) reviewed including Home Visit (HV) # 1, HV # 3, HV # 7, MR # 4, MR # 1, and had the potential to affect all patients served by the agency.



Findings include:



Policy: Monitoring Medications

Policy Number: 10.008

Revised date: 05/01/19



Policy:

A drug regimen 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:

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 orders 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, and medical marijuana (in states where legalized), to identify issues as:



vii. Duplicate drug therapy

ix. Dosage errors; and

x. Drug omissions



6. Notify the physician of any of the above identified issues/ discrepancies. Collaborate with the Patient Care Manager and ensure that supportive documentation is evident in the medical record.



1. HV # 1 was admitted on 8/25/19 with diagnoses including Hypertensive Heart Disease With Heart Failure and Chronic Systolic (Congestive) Heart Disease.



A home visit was conducted on 11/19/19 at 11:30 AM with Employee Identifier (EI) # 11, Registered Nurse (RN) to observe RN assess and perform intravenous (IV) infusion.



The following medications were observed in home, reconciled as current by the patient, and not listed on the agency Client Medication Report(CMR) provided by the agency on 11/19/19 at 1:30 PM.

1. Magnesium Oxide 1 tablet three times a day started 8/25/19

2. Protonix 40 (milligram) mg. 1 tablet daily started 10/10/19

3. Hydralazine 10 mg tablet three times a day. Medication not listed on the agency printed CMR provided.

The following medication observed in the home had from the CMR:

1. Torsemide 120 mg 6 tablets two times a day as written in the CMR.

2. Torsemide 120 mg mg 4 tablets two times a day with meals, as written on the medicine bottle found at home.

The discrepancy found was the difference between the number of tablets written on the CMR from the number of tablets written on the patient's medication bottle



An interview was conducted on 11/20/19 at 8:30 AM with Employee Identifier (EI) # 1, Adminstrator who confirmed the above mentioned findings.



2. HV # 3 was admitted on 11/11/19 with diagnoses including Hypertensive Chronic Kidney Disease (CKD), Type 2 Diabetes Mellitus (DM), and Rheumatic Mitral Insufficiency.



A home visit was conducted on 11/19/19 at 12:05 PM with EI # 9, Physical Therapy Assistant (PTA). The surveyor was accompanied by EI # 10, RN/Patient Care Manager (PCM).



The following medications were observed in home, reconciled as current by the patient, and not listed on the agency CMR provided by the agency on 11/19/19 at 11:45 AM:



1. Labetalol 200 MG tablets- Take 4 tablets (tabs) by mouth every 12 hours. Fill date 11/9/19.



2. Hydralazine 100 MG tabs- Take one tablet (tab) by mouth every 8 hours. Fill date 11/9/19.



Skilled Nurse (SN) visits were made 11/11/19, 11/14/19, and 11/18/19.



The following medication was observed at the home but with a different dosage from what was reviewed on the CMR:



1. Isosorbide mononitrate 20 MG tabs- Take one tab by mouth daily was listed on the CMR.



Isosorbide mononitrate 30 MG ER tabs- Take one tab by mouth every morning was observed in the home. Fill date 11/9/19.



An interview was conducted on 11/19/19 at 12:30 PM with EI # 10 at the time of the home visit, who confirmed the above findings



3. HV # 7 was admitted on 11/18/19 with diagnoses including Right Quadrant Pain, Salpingitis and Oophoritis, and Sepsis.



A home visit was conducted on 11/20/19 at 8:43 AM with Employee Identifier (EI) # 8, Licensed Practical Nurse (LPN) to assess and perform wound care with use of a Wound Vacuum-Assisted Closure (VAC). The surveyor was accompanied by EI # 3, RN/Clinical Director.



The following medications were observed in home, reconciled as current by the patient, and not listed on the agency CMR provided by the agency 11/19/19 at 8:10 AM:



1. Fluconazole 150 MG tablet-take one tablet (tab) by mouth every 72 hours. Fill date 11/15/19.



2. Loratadine 10 MG- take one tab daily as needed in a 24 hour period (as directed). Patient confirmed he/she was taking the medication prior to admission to agency.



The following medication was observed at the home but had a different dosage amount to be given compared to the dosage amount on the CMR:



1. Oxycodone-Acetaminophen Oral 10-325 MG 1 tab every 6 hours as needed.



Oxycodone-Acetaminophen Oral 10-325 MG- Take 2 tablets by mouth every 6 hours as needed was observed in the home. Fill date 11/15/19. Patient SN visit was made 11/18/19.



An interview was conducted on 11/20/19 at 11:10 AM with EI # 3, who confirmed the above findings.









4. MR # 4 was admitted to the agency 4/25/19 with diagnoses including Pilonidal Cyst With Abscess, Essential Hypertension, Type 2 Diabetes Mellitus With Diabetic Neuropathy Unspecified, and Hyperparathyroidism Unspecified.



Review of the medical record revealed MR # 4 was transferred to an inpatient facility on 5/6/19 due to elevated blood sugar, diabetes out of control.



Review of the facility discharge (d/c) instructions dated 5/8/19 and review of the resumption of care (ROC) order dated 5/9/19 revealed the following discrepancies:



a. Sensipar 60 mg oral tablet (tab), 1 tab by mouth once daily was listed as a new medication on the facility d/c instructions and was listed on the ROC order with a start date of 5/9/19. Cinacalcet 60 mg 1 tablet daily was also listed on the ROC order with a start date of 4/2/19. This is the same medication and both were listed as current medications. The SN failed to review medications for duplication.



b. Tresiba FlexTouch 200 units/ml (milliliter) subcutaneous 22 units once daily was listed on the facility d/c instructions and was not listed on the ROC order.



c. NovoLog 100 units/ml sliding scale before meals, max (maximum) 10 units/day was listed on the facility d/c instructions and was not updated on the ROC order.



An interview conducted on 11/21/19 at 1:40 PM with EI # 1 confirmed the patient was not taking the Tresiba as ordered and the Novolog had not been updated on the ROC order.



5. MR # 1 was admitted to the agency 8/30/19 with diagnoses including Other Symptoms and Signs Involving the Musculoskeletal System and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. MR # 1 was discharged from the hospital on 8/29/19.



Review of the Home Health Certification and Plan of Care dated 8/30/19 to 10/28/19 revealed one (1) medication - aspirin 81 mg one daily.



Review of the physician's order dated 9/3/19 for RX Rec (prescription reconciliation) revealed 22 medications added to the patient's medication list. The order was not sent to the physician for signature. The agency failed to provide a current and complete medication list to the physician.



Review of the MR revealed a Transfer Inpatient Facility dated 9/4/19 revealed the patient was hospitalized on 9/1/19. Further review revealed MR # 1 was discharged home on 9/14/19.



Review of the hospital discharge orders and the agency Resumption of Care (ROC) orders dated 9/15/19 revealed the following discrepancies:



a. Dexamethasone 1 mg tablet - 2 tabs oral every day for 4 days start 9/14/19 and end on 9/18/19 was listed on the hospital discharge order and not on the agency ROC order.



b. Dexamethasone 1 mg tablet - 1 tabs oral every day for 4 days start 9/18/19 and then dc (discontinue). Resume 5 mg of prednisone daily was listed on the hospital discharge and not on the ROC order.



c. Prednisone 5 mg 1 daily was on the ROC order with a start date 9/3/19 (patient was admitted to the hospital on 9/1/19) and not a start date of 9/23/19 after the dexamethasone would be completed as listed on the hospital discharge order.



Review of the Client Medication Report printed 11/19/19 revealed the following duplications:



a. Enzalutamide 40 mg 1 tab daily start 9/3/19 and Xandi 40 mg 4 tabs daily start 9/15/19. This is the same medication and both are listed as current.



b. Zofran 8 mg 1 tabs 3 times daily start 9/3/19 and Zofran 10 mg 2 tabs 4 times daily with a start date of 9/4/19.



The SN failed to assess for duplicate therapy.



An interview conducted on 11/21/19 at 11:20 AM with EI # 2 confirmed the above findings.