Dale Medical Center 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 observations, medical record (MR) review, agency policy and procedure, and interviews with staff, it was determined the agency failed to ensure an accurate medication list was maintained for each patient. This affected two of three home visit (HV) patients, including HV # 1 and HV # 3, and had the potential to affect all patients admitted to this agency. Findings include: Agency Policy: Medication Reconciliation Policy Number: 8.15.1 Purpose: To define the medication reconciliation process. Procedure: ...2. Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. 1. HV # 1 was admitted to the agency on 11/7/25 with a diagnosis of Pressure Ulcer of Left Heel, Stage 3. A HV was conducted on 12/29/25 at 1:01 PM to observe care provided by Employee Identifier (EI) # 3, Licensed Practical Nurse. During the HV, EI # 3 reviewed the medications with HV # 1 and compared the medications with the agency medication list. The following is a list of discrepancies: Docusate Sodium 100 milligrams (mg) take one capsule by mouth daily as needed for constipation, was listed on the medication list. HV # 1 stated he/she stopped taking about a month ago. Tylenol Extra Strength Rapid Release 500 mg two tablets by mouth every six hours as needed for pain, was listed on the medication list. HV # 1 stated he/she currently takes one tablet every morning and one tablet every evening. An interview was conducted on 12/30/25 at 4:10 PM with EI # 6, Director, who confirmed the medications were not reconciled per agency policy and procedure. 2. HV # 3 was admitted to the agency on 12/3/25 with a diagnosis of Urinary Tract Infection, site not specified. A HV was conducted on 12/30/25 at 10:55 AM to observe care provided by EI # 2, Certified Nursing Assistant. During the HV, the surveyor reviewed the medications with HV # 3 and compared the medications with the agency medication list. The following is a list of discrepancies: Gabapentin 100 mg one capsule by mouth three times daily, was listed on the medication list. HV # 3 stated he/she was no longer taking and “...stopped taking a couple of months ago.” Omeprazole 20 mg one capsule by mouth as needed for acid reflux. HV # 3 stated he/she was no longer taking, but wasn’t quite sure when he/she stopped. An interview was conducted on 12/30/25 at 4:10 PM with EI # 6, Director, who confirmed the medications were not reconciled per agency policy and procedure.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on a review of the agency reference manual, medical record (MR), and interviews with staff, it was determined the agency failed to measure Peripherally Inserted Central Catheter (PICC) line catheter with each dressing change. This deficient practice affected one out of one MR reviewed with a PICC line, including MR # 6, and had the potential to affect all patients served by the agency. Findings Include: Agency Reference Manual: The Visiting Nurse Associations of America VNAA Clinical Procedure Manual 18th Edition. Section: 08.07 Last revised: 9/12 Title: Infusion Therapy - Central Line Type: PICC Considerations: 6. Site Care ...D. Dressing Change Equipment:... …Procedure:… …13. Verify the external catheter length visible outside corresponds to initial placement measurement. If it does not, notify physician before continuing use. 1. MR # 6 was admitted to the agency on 11/21/25 with a primary diagnosis of Type 2 Diabetes Mellitus with Foot Ulcer. Review of the MR demonstrated a certification period of 11/21/25 to 1/19/26. Further review of the MR demonstrated a PICC line was placed on 12/1/25. Review of the MR on 12/30/25 demonstrated no record of the PICC line external catheter length measurements being obtained with the ordered weekly PICC line dressing change. An interview was conducted with EI # 6, Director, on 12/30/25 at 4:05 PM who confirmed there was no documentation to support the PICC line external catheter length was measured with the PICC line dressing changes.”