Lady of the Sea Home Health Agency

“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, interview, and record review the agency failed to ensure a patient’s medication profile was complete and accurate for 1 (Patient #3) of 3 sampled patients reviewed for medication reconciliation. Findings: Review of the agency’s Medication Management Policy, revised on 11/2017 revealed, in part, the skilled nurse was to review the patient’s medication list on each skilled nurse visit. Review of Patient #3’s Home Health Certification and Plan of Care for the certification period of 11/13/2025 through 01/11/2026 revealed, in part, Patient #3 was to receive skilled nursing services once a week for eight weeks. Review of Patient #3’s Medication Profile dated 12/08/2025, which was provided to the surveyor as the most accurate medication list, revealed, in part, no documented evidence Methanamine Hippurate, Clopidogrel and Januvia were documented as current or discontinued medications. Observation on 12/16/2025 at 10:45 a.m. revealed the following medications were present in Patient #3’s home: Methanamine Hippurate (a medication used to prevent urinary tract infection) with a prescription fill date of 8/11/2025, re-fill date of 11/17/2025; Clopidogrel (a blood thinner used to prevent problems with heart and blood vessels) with a prescription fill date of 7/15/2025, re-fill date 10/9/2025; and, Januvia (a medication used to control blood sugar levels) with a prescription fill date of 8/18/2025, refill date 11/17/2025. In an interview on 12/16/2025 at 11:12 a.m., Patient #3’s caregiver indicated Patient #3 was currently prescribed Methanamine Hippurate, Clopidogrel, and Januvia daily. Patient #3’s caregiver further indicated the above-mentioned medications had been prescribed for a while now. In an interview on 12/16/2025 at 11:15 a.m., S3 Registered Nurse (RN) confirmed the above medications were not listed on Resident #3’s medication profile as required. In an interview on 12/16/2025 at 12:32 p.m., S2Director of Nursing (DON) indicated the nursing staff should have identified the prescriptions and updated Patient #3’s profile when performing medication reconciliation at each skilled nurse visit as required.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure medication orders contained the medication dose, frequency, route, and purpose as required by standards of practice for 1 (Patient #1) of 7 sampled patients reviewed for care and services. Findings: Review of National Coordinating Council for Medication Error Reporting and Prevention Recommendations to Reduce Medication Errors Alert dated 05/01/2025 revealed, in part, verbal orders for medication should include drug name, dosage, frequency, route, and purpose. Review of the agency’s Medication Management policy, revised on 11/2017, revealed medication orders should contain, in part, dosage, frequency, route, and purpose. Review of Patient #1’s verbal order received by S2Director of Nursing (DON) on 10/02/2025 revealed orders for, in part, doxycycline (medication used to treat infection) for five additional days, and to resume Farxgia (medication used to treat diabetes). Further review revealed neither medication order contained the dose, frequency or route. Interview on 12/6/2025 at 4:00 p.m., S2DON confirmed the above mentioned verbal orders did not contain the dose of medication, the frequency of medication, or the route of the medication as required.”