Ace Home Health, Inc.

“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 observation, interviews, and record review, the Home Health Agency (HHA, an organization that provides skilled nursing and therapeutic services to a patient at home) failed to conduct a comprehensive review of all medications the patient was currently taking for two of seventeen (17) sampled patients (Patient 12 and Patient 13) who lived in an Assisted Living Facility (ALF) by failing to: This failure had the potential for Patient 12 and Patient 13 to be at risk for medication error and serious adverse effects, including being unable to treat pain properly, leading to continued suffering and unmanaged symptoms. A. During a review of Patient 12’s Home Health Certification and Plan of Care (POC- a physician-established document that certifies the patient’s needs for home health services and sets forth the individualized plan of care to be followed by the HHA), for the certification period of 8/4/2026 through 10/2/2026, the POC indicated Patient 12 was admitted to the HHA with diagnoses that included ataxia (disorders that affect co-ordination, balance and speech) following cerebral infarction (stroke), muscle weakness (reduced muscle strength), abnormality of gait (abnormal pattern or manner of walking that may affect mobility, balance, and the patient’s ability to safely perform activities). The POC indicated an order for skilled nursing visits at a frequency of 1 visit per week for 6 weeks (1w6) and 2 PRN (as needed) visits for medical problems. The POC indicated SN to assess pain level and effectiveness of pain medications and current therapy every visit. The POC indicated to instruct the Patient/Caregiver on medication regimen does, indications, side effects and interactions. During a review of Patient 12’s, “Admission Order Form,” dated 8/4/2026, the admission order form indicated instructed the skilled nurse (SN) to assess medication effects and compliance. During a review of Patient 12’s medication profile, dated from 8/4/2026 to 10/2/2026, the medication profile indicated for Acetaminophen Oral, 325 mg (milligram, a unit of measure), 2 tab(s) by mouth every 6 hours as needed for pain. The medication profile did not indicate for Docusate Sodium (medication used to help prevent or treat constipation by making stools softer and easier to pass), 100 mg soft gel, take 1 capsule by mouth twice daily. During a concurrent observation and interview on 9/3/2026 at 11am, with the Registered Nurse (RN 1) and the Administrator/Director of Patient Care Services (ADM/DPCS), at a home visit at the ALF where Patient 12 resided, Patient 12 medications were observed. The following was observed: 1) A bubble pack containing Acetaminophen 500 mg, 2 tablets as needed for pain, with a fill date of 1/18/2026 and 2) a bubble pack containing Docusate Sodium (medication used to help prevent or treat constipation by making stools softer and easier to pass), 100 mg soft gel, take 1 capsule by mouth twice daily. RN 1 stated she did not review the patient’s physical medications and obtained the medication information from the ALF Medication Administration Record (MAR). The ADM/DPCS stated medications should be reviewed at every visit to ensure their effectiveness and safety. During an interview on 9/3/2026 at 12 pm, with the ALF’s Clinical Manager, the ALF’s Clinical Manager stated that the current physician’s order maintained at the ALF, dated 1/17/2026 for Acetaminophen 500 mg every 6 hours as needed for pain. The clinical manager stated the ALF had not updated its medication administration record (MAR) to reflect the current physician’s order and the MAR continued to reflect the previous acetaminophen order. The Clinical Manager further stated that the acetaminophen 500 milligrams was present in patient 12’s medication box along with the acetaminophen 325 mg and that the pharmacist at the ALF should have reviewed and updated the medications. B. During a review of Patient 13’s Home Health Certification and Plan of Care, the POC indicated a start of care date of 7/25/2026 and a certification period from 7/25/2026 through 9/22/2026. The POC indicated diagnoses that included hypertensive heart and chronic kidney disease with heart failure (high blood pressure associated with disease affecting the heart and kidneys, with heart failure present )and stage 1 through stage 4 or unspecified chronic kidney disease (a long-term health condition where your kidneys are damaged and slowly lose their ability to filter waste and extra fluid from your blood), chronic diastolic congestive heart failure (a long-term condition in which the heart has difficulty relaxing and filling adequately, which can contribute to congestion , and chronic atrial fibrillation [a persistent irregular heart rhythm originating in the atria that can affect cardiac function and is associated with an increased risk of blood clots and stroke]). The POC indicated for skilled nursing visits at a frequency of 1w1, 3w6, 1w4, and 2 PRN visits. During a observation on 9/3/2026 at 11:30am, with the Registered Nurse (RN 1) and the Administrator/Director of Patient Care Services (ADM/DPCS), at a home visit at the ALF where Patient 13 resided, Patient 13’s medications were observed in the medication room. Docusate Sodium (DSS is a stool softener used to prevent or treat constipation by softening the stool and making bowel movements easier to pass), 100 mg , and Seroquel (quetiapine -is an atypical antipsychotic medication used to treat certain mental health conditions, including schizophrenia and bipolar disorder) 25 mg, medication was observed during the medication reconciliation. During a concurrent interview and record review on 9/3/2026 at 11:30 a.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 13’s Medication Profile and ALF Medication Administration Record (MAR) was reviewed. The following medication discrepancies were identified: 1.The ALF MAR indicated for Docusate Sodium 100 mg, 1 capsule twice daily, with a fill date of 8/5/2026, and the HHA Medication profile did not indicate for Docusate Sodium 100mg. 2.The ALF MAR did not indicate for Acetaminophen 325 mg, 2 tablets as needed and the HHA’s medication profile indicated for Acetaminophen 325 mg, 2 tablets as needed. 3.The ALF MAR indicated for Seroquel (quetiapine ) 25 mg, 1/2 tablet once daily as needed,(is an atypical antipsychotic medication used to treat certain mental health conditions, including schizophrenia and bipolar disorder, and may also be used with other medications to treat major depressive disorder) and the HHA’s medication profile did not indicate for Seroquel 25 mg. During an interview on 9/3/2026 at 11:00 am, RN 1 stated she did not review the patient’s physical medications and obtained the medication information from the ALF Medication Administration Record (MAR). During an interview on 9/3/2026 at 11:00 am, the ADM/DPCS stated medications should be reviewed at every visit to ensure their effectiveness and safety. During a review of the HHA’s policy and procedure titled “Medication Reconciliation for Patients (ALF),” effective 6/10/2022, indicated the purpose was to establish a standardized process for medication reconciliation for patients residing in Assisted Living Facilities and to ensure that the Home Health clinical record reflects an accurate and current medication regimen. The policy indicated that the agency shall maintain an accurate and current medication profile for patients residing in an ALF. Medication reconciliation shall be performed at Start of Care (SOC), Resumption of Care (ROC), following transitions of care, when medication changes or discrepancies are identified, and as clinically indicated. The Home Health medication profile shall be updated to reflect verified medication changes. The procedure indicated that at SOC and ROC, the clinician shall review and reconcile the patient’s current medication regimen using available and appropriate sources, including physician/provider orders, the ALF MAR, hospital discharge information, pharmacy records, and other relevant clinical documentation. During subsequent visits, the clinician shall assess medication changes or discrepancies as clinically indicated. When a medication change is identified, the clinician shall verify the change through an appropriate source and update the Home Health medication profile accordingly.”