| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 017050 | (X3) Date Survey Completed 01/06/2023 |
| Name of Provider or Supplier Central North Alabama Health Services, Inc. | Street Address, City, State 1310 Pulaski Pike, Unit A, Huntsville, 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), agency policy and procedure, observation, and interviews, it was determined the agency failed to ensure the Medicine Profile (MP) was current and accurate for all patients. This affected one of two Home Visits (HV) conducted, and did affect HV # 1, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: Medication Reconciliation Policy Number: None Revision/Review Date: None Policy: The agency will reconcile patient's medications at time of admission and on an ongoing basis. Procedure: ...2. ...The medication list/profile will be updated with each new or changed medication. 1. HV # 1 was admitted to the agency on 11/10/22 with diagnoses including Lymphedema, Not Elsewhere Classified, and Unspecified Open Wound Abdominal Wall, Unspecified Quadrant Without Penetration Peritoneal Cavity Initially. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 11/10/22 to 1/8/23 revealed orders for a Skilled Nurse (SN) visit frequency of one time a week for one week, then two times a week for eight weeks. A HV was conducted on 1/4/23 at 1:37 PM to observe care provided by Employee Identifier (EI) # 1, Registered Nurse (RN). During the HV, a comparison was made between medications observed in the home and the MP provided to the surveyor on 1/4/23. The following discrepancies were observed: a. Folic Acid one milligram (MG), one tablet every day was listed on the MP. The patient stated his/her physician stopped the folic acid in December 2022. b. Furosemide 40 MG, one tablet once a day was listed on the MP. The patient stated he/she had not taken a dose of furosemide in a month. c. Two bottles of Levothyroxine 50 micrograms (MCG), one with fill date 11/15/22, the second with fill date 12/22/22 were observed in the home. Levothyroxine was not on the ML. The patient stated he/she took the Levothyroxine daily. d. Nystatin Cream 100,000 units with fill date 12/20/22 was observed in the home and not on the ML. The patient stated he/she currently used the Nystatin Cream as needed, and had used it as needed for years. e. Nystatin Powder 100,000 units with fill date 12/20/22 was observed in the home and not on the ML. The patient stated he/she currently used the Nystatin Powder as needed, and had used it as needed for years. An interview with EI # 1 on 1/6/23 at 3:32 PM confirmed the ML was not current and accurate for HV # 1. |