Highlands Home Health

“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 with staff, it was determined the agency failed to ensure medications were reconciled in one of six MRs reviewed and three of four Home Visits (HV) conducted. This affected MR # 2, HV # 1, HV # 3, HV # 4, and had the potential to negatively affect all patients 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 # 3 was admitted to the agency on 8/2/24 and recertified from 1/29/25 to 3/29/25 with a primary diagnosis of Hypertensive Heart Disease with Heart Failure. A HV was conducted on 2/4/25 at 1:00 PM to observe care provided by EI # 2, Registered Nurse. During the HV, the CMR was compared to the medications the patient was currently taking. The following was observed: a. Lasix 40 mg tablets, take one tablet every other day, with a fill date of 1/13/25 . HV # 3’s caregiver (CG) stated he/she had been taking it for “a long time.” b. Olmesartan 40 mg tablets, take one tablet every morning, with a fill date of 11/25/24. HV # 3’s CG stated the patient had been taking it “at least two or three years.” c. Loperamide 15 milliliters daily, take only as needed (PRN) for diarrhea was on the CMR, but HV # 3’s CG stated he/she stopped taking it in October. An interview was conducted on 2/6/25 at 11:17 AM with EI # 1, who confirmed the staff failed to follow the policy for monitoring medications. 4. HV # 4 was admitted to the agency on 1/6/25 with a primary diagnosis of Hemiplegia and Hemiparesis That Occurs After a Cerebral Infarction Affecting the Right Side of the Body. A HV was conducted on 2/4/25 at 11:35 AM to observe care provided by EI # 3, Certified Occupational Therapy Assistant. During the HV, the CMR was compared to the medications the patient was currently taking. The following OTC medications were observed in the home and not on the CMR: a. Docusate Sodium 100mg, take one tablet daily. b. Flintstones Vitamins chewable tablets, chew one tablet daily. c. Multi-Enzyme Probiotic, take one tablet daily. d. Omega-3 500 mg tablets, take one tablet daily. e. Melatonin 10 mg tablets, take one at bedtime. f. Extra Strength Tylenol 500 mg tablets, take one tablet daily and PRN. An interview was conducted during the HV with HV # 4, who confirmed he/she had been taking the OTC medications “for a long time.” Additionally, Amlodipine 5 mg tablet, take one tablet daily, and Red Yeast Rice 600 mg capsule, take one capsule daily, were on the CMR but not in the home. An interview was conducted on 2/6/25 at 11:19 AM with EI # 1, who confirmed the staff failed to follow the policy for monitoring medications. 1. MR # 2 was admitted to the agency on 1/7/25 with a primary diagnosis of Pressure Ulcer of Other Site, Stage Three. Review of the physician order dated 1/21/25 revealed an order for right medial great toe. Cleanse with Dakins, apply Santyl, non stick dressing, secure with Kling and tape daily. Review of the physician order dated 1/27/25 revealed an order for right medial foot. Cleanse with Dakins, apply Alginate with Silver, conforming roll gauze, secure with tape. Review of the Client Medication Report (CMR) revealed no documentation of Dakins, Santyl and Alginate with Silver was on the CMR. An interview conducted on 2/6/25 at 11:29 AM with EI # 1, Executive Director (ED) confirmed the staff failed to reconcile the CMR. 2. HV # 1 was admitted to the agency on 1/20/25 with a primary diagnosis of Unilateral Primary Osteoarthritis of the Right Knee. A HV was conducted on 2/4/25 at 1:15 PM to observe EI # 5, Physical Therapist (PT) provide patient care. During the HV, the CMR was compared to the medications the patient was currently taking. The following was observed: a. Tizanidine 4 milligram (mg) tablet, take one tablet two times daily, was on the CMR. HV # 1 stated, “I stopped that medication about 4-5 weeks ago. It ran out and I did not get it refilled.” b. Vitamin C 500 mg tablet, take one daily, was on the CMR. HV # 1 stated, “I stopped that medication about 2 months ago, it caused stomach problems.” c. Simvastatin 40 mg tablet, take one daily, was not on the CMR but was observed in the home. HV # 1 stated, “I have been taking that medication for about 4-5 years.” An interview conducted on 2/6/25 at 11:22 AM with EI # 1 confirmed the staff failed to follow the policy for monitoring medications.”