Centracare 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 observation, interview, and document review, the agency failed to complete a comprehensive drug regimen review to ensure the accuracy of all medications/dosages for 1 of 7 patients (P12) whose medications were reviewed. P12’s plan of care (POC) indicated start of care (SOC) date of 2/7/26. The POC for the certification period 2/7/26 to 4/7/26, included diagnoses of chronic pain, osteoarthritis, diabetes, chronic congestive heart failure, kidney disease, and long-term use of oral hypoglycemic drugs. The POC further indicated P3 received skilled nurse visits every week for various assessments and education, including medication management and instruct patient on specific medications related to diagnoses. P12’s POC included the following medications: enteric coated aspirin 81 milligram (mg) po daily; gabapentin (used to treat seizures or nerve pain) 300 mg two capsules at bedtime: ferrous sulfate 324 mg 1 tablet po two times per day; levothyroxine (to treat hypothyroidism) 125 microgram (mcg) every morning: lisinopril (to treat high blood pressure) 10 mg every day: omeprazole (to treat stomach acid) 40 mg every day: Percocet 10-325 mg (opioid pain medication) one tablet every eight hours as needed: and Senokot-S (a laxative) 8.6-50 mg one tablet as directed. P12’s Active Medications list printed 2/23/26, identified the following medications: allopurinol 100 mg two times per day: enteric coated aspirin 81 mg po daily; gabapentin 300 mg two capsules at bedtime: furosemide (to treat fluid retention) 20 mg in the morning: ferrous sulfate 324 mg 1 tablet po two times per day; levothyroxine 125 mcg every morning: lisinopril 20 mg every day: nystatin powder topically as needed: omeprazole 40 mg every day: oxybutynin (for urinary frequency)5 mg every morning: Percocet 10-325 mg one tablet every eight hours as needed: Senokot-S (a laxative) 8.6-50 mg one tablet as directed and simvastatin (for cholesterol) 20 mg at bedtime. P12’s Physician Office Visit note dated 2/4/26, identified P12 was seen by her primary care provider (PCP). A home health care referral was ordered and medications were reviewed. Current medications were listed which included medications that were not listed on her POC or Active Medications list from the home health agency. Medications not listed on P12’s POC or active medication list included: acetaminophen 500 mg (patient reports not taking); albuterol 2.5 mg/3 millimeters (ml) by nebulization route every six hours as needed for wheezing: colchicine 0.6 mg one tablet every 12 hours (patient reported not taking): duloxetine (an antidepressant) 30 mg daily: Flonase 50 mcg nasal solution into nostrils daily at bedtime: Advair 250-50 one puff two times per day: glipizide (to treat diabetes) 10 mg two times per day with meals: Duo Neb one vial every six hours as needed for wheezing: Jardiance (to treat diabetes) 10 mg every day: lidocaine 5 ml every three hours as needed for pain: metformin (to treat diabetes) 1000mg two times per day with meals: oxygen two liters per minute daily and as needed: and polyethylene glycol 17 grams every day as needed for constipation. New medication orders documented during the encounter were identified as albuterol nebulizer solution to be used by nebulization every six hours for wheezing, oxybutynin 5 mg every day for urinary frequency and nystatin powder for Intertrigo (an inflammatory skin condition) two times per day. P12’s electronic Medication List with review date 2/7/26, identified medications on P12’s POC that patient reported not taking, taking, not on the POC, and recently ended. However, this medication list did not address the following medications of acetaminophen, duloxetine, albuterol nebulizer, Advair, Duo Neb, Jardiance, oxygen, and polyethylene glycol. Review of skilled nurse visit note on admission 2/7/26, identified P12 was being seen for start of care to home care services. Medication management was reviewed and identified P12 was not taking medications as prescribed. Review of hypoglycemic medications documented none were being taken and no orders for these medications were noted in P12’s chart. The visit documented a complete drug review was completed and identified potential clinically significant medication issues; however, the agency did not contact P12’s PCP for recommended actions to the identified significant medication issues. The admission assessment also failed to identify orders for oxygen and nebulizer treatments and had recorded supplemental oxygen use and has nebulizer as no on the assessment form. The narrative notes for the visit identified P12 was non-compliant with every type of treatment, including diabetes and chronic obstructive pulmonary disease (COPD) and frequently refused medications or took the prescribed medications sporadically. P12 had some medication bottles in her current temporary residence and reported her other medications were in another location and did not have them available to her. Medication bottles P12 currently had were listed as follows: enteric coated aspirin 81 mg, levothyroxine 125 mcg, omeprazole 40 mg, Percocet 10-325 mg that she was taking daily and ferrous sulfate 324 mg, lisinopril 20 mg and Senokot-S (a laxative) 8.6-50 mg that she was taking, however not daily. P12 was instructed on importance of all prescribed medications. P12’s admission visit note lacked documentation if her newly prescribed medications and nebulizer treatment was reviewed or if she had the newly ordered prescriptions available. P12’s admission note identified P12’s PCP was notified she was non-compliant with her medications and treatments, however, did not notify the PCP which medications P12 was taking incorrectly or not at all nor request for recommended actions related to the missing prescriptions and non-compliance. During a home visit on 2/24/26, at 8:00 a.m. P12 had several medication bottles on a table in her living room. Medication bottles of aspirin 81 mg, gabapentin 300 mg, ferrous sulfate 324 mg, levothyroxine 125 mcg, lisinopril 10 mg, omeprazole 40 mg, Percocet 10-325 mg, Senokot-S 8.6-50 mg, duloxetine 30 mg, cephalexin 500 mg, P12 stated she did not take the medications every day, only when she felt she needed them. P12 stated she had other medications in the home packed in boxes but was not currently taking any other medications. During interview with the administrator and clinical manager (CM)-B on 2/24/26, at 3:45 p.m. the administrator stated the agency listed the medications on the POC as what the patient actually reported taking. Sometimes there would be a need to follow up with the PCP. The nurse was to identify what was prescribed and what the patient reported was actually taking in the electronic record. If there were discrepancies noted, the nurse would need to make a note in the chart which would get routed to the PCP, such as the patient was not taking a certain medication as directed or not taking the medication at all or whatever the discrepancy was about. CM-B stated all of P12’s prescribed medications from her clinic visit 2/4/26, should have been addressed on the POC and medication list and the PCP notified of which specific medications P12 was non-compliant with. All medications noted on the referral would need to be addressed individually with the patient on admission and the provider notified of all the medications P12 was not taking or taking incorrectly. During telephone interview on 2/25/26, at 8:13 a.m. registered nurse (RN)-A stated she usually compared medications in the home with the medication list on the referral. RN-A admitted P12 on 2/7/26, and used the clinic visit note and referral on 2/4/26, as P12’s current medication list. RN-A stated she reviewed the medication bottles P12 currently had in her home and then went through the referral medication list one by one. P12 told her which of the medications she was actually taking and if she was taking the medication differently then ordered as well as the medications she was not taking at all. RN-A notified P12’s PCP of the medications P12 had reported she was taking and just assumed the provider would understand P12 was not taking all the ordered medications listed on the referral medication list. The agency policy Medication Management dated 2/2025, identified the clinician would perform a drug regimen review on admission and after any updates to the medication profile was made. The drug regimen review would include a review of all the medications the patient was currently using and noncompliance with drug therapy. The physician would be notified promptly of any actual or potential medication problems, based on clinical judgement.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on interview and document review the facility failed to document code status on the plan of care (POC) for 3 of 17 (P1, P2, P10) patients reviewed for required documentation on the POC. Findings include P1’s POC dated 2/2/26 to 4/2/26, indicated a start of care (SOC) date of 6/12/24. The section Advanced Care Planning indicated P1’s code status as “Prior”. P1’s medical record lacked an order for a code status such as full code or do not resuscitate. P2’s POC dated 1/24/26 to 3/24/26, indicated a SOC of 5/29/25. The section Advanced Care Planning indicated P2’s code status as “Prior”. P2’s medical record indicated on 5/29/25, an order for Full Code was received from the provider. P10’s POC dated 12/29/25 to 2/26/26, indicated a SOC of 9/1/23. The section Advanced Care Planning indicated P10’s code status as “Prior”. P10’s medical record indicated on 3/1/25, an order for Full Code was received from the provider. During an interview on 2/24/26 at 1:30 p.m., registered nurse (RN)-B stated a code status of prior indicated the code status had not been reviewed and entered into the POC. When staff saw a code status of prior, they knew the code status still needed to be reviewed with the client. During an interview on 2/24/26 at 4:18 p.m., the administrator and clinical manager (CM)-B both stated a code status of “prior” meant the code status needed to be addressed with the client and entered into the POC. With a code status of “prior”, staff would not know if the patient wanted cardiopulmonary resuscitation (CPR) performed or not if the heart stopped or if they stopped breathing. The administrator and CM-B reviewed P1’s POC and medical record and acknowledge there was a code status of prior and there had been no orders received related to code status since SOC. The administrator and CM-B reviewed P2’s and P10’s POC and medical record. Both acknowledged a code status of “prior” on the POC’s. They acknowledged P2 and P10 both had orders for full code that were not on the current POC. The code statuses had been on an older POC but had fallen off when the patient went to the emergency room (ER). Since the electronic medical record is the same the hospital, the code status falls off when the patient goes to the ER. The expectation was the nurses would review the POC with each recertification and address the code status as part of the recertification visit and not leave the code status as “prior”. Agency policy Care Planning Process last revised 4/25, indicated information related to advanced directives (code status) would be included on the POC. The POC would be reviewed initially and then every 60 days at minimum after that by all disciplines involved.”