Hancock County Health System Community 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, patient interviews, staff interview, clinical record reviews and agency policy review, the agency failed to complete an accurate drug regimen review with each comprehensive assessment for 2 of 3 sampled patients with home observation visits (Patients #1 and #3). Failure to ensure medications reviewed at the time of each drug regimen review are current and accurate placed the patients at risk for increased potential unidentified medication interactions, side effects and duplication of medications. Findings include: According to the agency policy titled Medication Reconciliation-Drug Regimen Review, dated 12/2022, the client’s medication profile identifies all medications the client is currently taking on a routine or as needed (prn) basis including: prescription and non-prescription medications, oxygen, vitamins, herbal, and nutritional supplements. During an interview on 1/7/26 at 9:20 AM the Administrator/Clinical Manager stated the Registered Nurse (RN) responsible to complete the Drug Regimen Review (DRR) at admission, recertification and discharge. 1.Patient #1 had a start of care date of 4/20/21. Clinical record review revealed the following: a. The Plans of Care (POCs), dated 9/26/25 to 11/24/25 and 11/25/25 to 1/23/26, identified the patient had a diagnosis of Schizoaffective disorder and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at recertification, dated 12/5/25, completed by Staff B, RN, included documentation a DRR was completed. c. During a home observation visit on 1/6/26 at 7:30 AM with Staff B, RN, the patient interview revealed the following medication discrepancies orders and patient stated medication schedule: Systane Complete Optimal Dry Eye Relief preserved ophthalmic solution; Apply 1 drop 4 times a day as needed for dry eyes; Apply 1 drop to each eye. Patient stated had not been taking for a long time and did not have the medication in the home. The DRR failed to include an accurate review of all medications taken by the patient. 2. Patient #3 had a start of care date of 5/6/25. Clinical record review revealed the following: a. The POCs, dated 9/21/25 to 11/19/25 and 11/20/25 to 1/18/26, identified the patient had a diagnosis of Chronic atrial fibrillation and included physician orders for medication and skilled nursing services. b. The comprehensive assessment at recertification, dated 11/18/25, completed by Staff C, RN, included documentation a DRR was completed. c. During a home observation visit on 12/9/25 at 2:00 PM with Staff C, RN, the surveyor noted Tums (calcium carbonate) 750 milligrams 2-3 tablets as needed for acid indigestion, heart burn. Patient family stated the patient had taken the medication for the last 5 months. The DRR failed to include an accurate review of all medications taken by the patient. The above findings were reviewed with the Administrator/Clinical Manager.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on patient interview, clinical record review and agency policy review, the agency failed to provide services only as ordered by the physician for 1 of 7 sampled patients (Patient #4). Failure to ensure staff obtain and follow physician orders for treatments provided by agency staff placed patients at risk for inconsistent care/treatment and possible harm. Findings include: According to the agency policy, titled Plan of Care Order, revised 3/2023, each patient receiving home care must have a written individualized plan of care that identifies patient specific measurable outcomes and goals. This plan of care must be established, reviewed no less than every 60 days. The individualized plan of care must include all medications and treatments. Patient #4 had a start of care date of 12/16/25. Clinical record review revealed: a. The POC, dated 12/16/25 to 2/13/26, identified the patient had diagnoses of Disc degeneration and left hip bursitis, and included skilled nurse orders to assess weight change. b. Skilled nurse note at start of care dated 12/16/25, included documentation of patient weight of 140.76 pounds. c. Review of the clinical record failed to include further documentation of the patient’s weight. Agency staff failed to include assessment of the patient’s weight. The above findings reviewed with the Administrator/Clinical Manager.”