Reid-Anc Home Care Services LLC

“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, record review, and interview, the agency failed to complete a comprehensive review of medications for 2 of 5 skilled nursing home visits completed. (Patient #1, 4) Findings Include: 1.A policy titled, “Plan of Care and Physician and Allowed Practitioner Orders” revised 03/05/2024 indicated the plan of care should be based upon a current assessment of the patient’s needs for care and must include all medications. 2. A policy titled, “Medication Profile” revised 01/21/2025 indicated the medication profile will be updated at resumption of care, recertification, at discharge, and with any medication changes. 3. During a home visit on 09/15/2025 at 10:00 AM, RN 9 reviewed Patient #1’s current medications with him/her using a hospitalization discharge summary from Patient #1’s last hospitalization and compared that list to the agency medication list. The medication bottles in the home were not reviewed by RN 9. The clinical record for Patient #1 evidenced the following: A document titled, “Client Medication Report” dated 09/11/2025 and a document titled, “Home Health Certification and Plan of Care” for recertification period 07/20/2025 - 09/17/2025 for Patient #1 included the following medications Patient #1 was no longer taking: Azelastine/Fluticasone Nasal Spray (medication used to treat seasonal allergies), Vitamin B-12 (supplement), Diclofenac 1% Topical Gel (used to treat pain), Miralax (used to treat constipation), Vesicare (used to treat an overactive bladder). The following medications listed in the plan of care and medication report were incorrect doses/frequencies: Omeprazole (used to treat acid reflux) 20 mg daily, Patient #1 was taking 40 mg twice a day. Potassium Chloride (supplement) 20 milliequivalents daily, Patient #1 was taking twice daily. During an interview on 09/15/2025 at 11:05 AM, RN 9 indicated she was unsure when Patient #1’s last hospitalization was that she was using to complete the medication review. Patient #1 indicated he/she thought it was in May of 2025, and RN 9 indicated she thought it was either June or July of 2025. When the medication review was completed with Patient #1 the surveyor asked about medications listed on the medication report and plan of care that were not discussed to include Azelastine/Fluticasone, Vitamin B=12, Diclofenac, Miralax, and Vesicare. RN 9 asked Patient #1 about the medications and Patient #1 indicated he/she was not taking any of those medications. RN 9 indicated that all medications are reviewed at each recertification and that she had completed the last recertification but failed to review the medications. RN 9 could not advise when the last medication review was completed with Patient #1. During an interview on 09/15/2025 at 11:00 AM, Patient #1 indicated that the agency does not look at his/her medication bottles when reviewing current home medications, staff typically ask if he/she is taking any new medications during visits. 4. During a home observation on 09/12/2025 at 2:15 PM, RN 9 failed to review medications for Patient #4 during the home visit. 5. During an interview on 09/15/2025 at 2:45 PM, the Administrator indicated the expectation if that staff review medications at every visit.”

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the revised plan of care included information concerning the patient’s progress towards measurable outcomes and goals for 3 of 3 revised plan of cares reviewed. (Patient #1, 3, 5) Findings include: A clinical record for Patient #3, SOC 09/04/2024, certification period 08/20/2025 to 10/28/2025, failed to evidence information concerning the patient’s progress toward measurable outcomes and goals. A clinical record for Patient #5, SOC 10/23/2024, certification period 08/19/2025 to 10/17/2025, failed to evidence information concerning the patient’s progress toward measurable outcomes and goals. A policy titled, “Plan of Care and Physician and Allowed Practitioner Orders”, revised 03/05/2024, indicated the plan of care must include progress towards goals identified and measured outcomes. A clinical record for Patient #1, SOC 04/07/2022, certification period 07/20/2025 - 09/17/2025, failed to evidence information concerning the patient’s progress toward measurable goals and outcomes. During an interview on 09/16/2025 at 1:40 PM, the Administrator indicated the updated plan of care does not include progress towards patient goals and outcomes.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to integrate services between the agency and Entity #1 on 1 of 1 clinical records reviewed. (Patient #2) Findings include: The clinical record for Patient #2, SOC 08/20/2025, failed to evidence documentation of communication between the home health agency and entity #1. During an interview on 09/12/2025 at 11:15 AM, LPN #1 indicated that she was unaware of who writes the orders for Patient #2. She indicated that she always checks in with Entity #1’s nurse for any new orders. A policy titled, “Case Conference and Coordination of Services” revised 07/2/2022 indicated care will be coordinated with other involved external organizations. Relevant information will be shared to facilitate appropriate continuity and care coordination. During an interview on 09/15/2025 at 3:40 PM, the Administrator indicated care conference meetings regarding patients are completed weekly with agency staff. Patients residing in assisted living facilities like Patient #2 are discussed, however, the assisted living facility coordination is not documented in the patient’s medical record.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to ensure services listed in the plan of care were provided for 1 of 5 skilled nursing assessments completed. (Patient #4) Findings Include: A policy titled, “Plan of Care and Physician and Allowed Practitioner Orders” revised 03/05/2024 indicated all care and services provided are according to current physician or allowed practitioners orders. A document titled, “Home Health Certification and Plan of Care”, certification period of 08/31/2025 - 10/29/2025 for Patient #4 indicated orders for a respiratory assessment and vital signs to be completed During an observation of a skilled home visit for Patient #4 on 09/12/2025 from 2:15 PM - 4:00 PM, RN 9 failed to assess Patient #4’s respiratory status, and failed to obtain his/her vital signs to include a blood pressure, pulse, and respiration rate. Patient #4 was audibly heard wheezing. RN 9 asked Patient #4 if he/she was wheezing during his/her wound care treatment with Patient #4 responding, “I don’t know”. During an interview on 09/15/2025 at 11:05 AM, RN 9 indicated she did not complete a respiratory assessment for Patient #4 to include auscultating (listening) his/her lungs or obtain a blood pressure, pulse, or respiration rate despite hearing audible wheezing. RN 9 indicated she obtained Patient #4’s temperature as it was the most relevant part of the assessment due to wound findings. During an interview on 09/15/2025 at 2:45 PM, the Administrator indicated that a respiratory assessment would include auscultating the lungs if present on the plan of care. She also indicated the expectation is for clinical staff to obtain vital signs at each visit.”