International Quality Homecare

“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 facility failed to evaluate all medications at time of recertification and address provider concerns to ensure all ordered medications were documented correctly. This affected 1 of 3 (P1) patients reviewed for medication administration. Findings include: During a home visit on 10/15/25 at 9:18 a.m., register nurse (RN)-A was observed setting up P1’s medication for a weeklong period. Glipizide 5 milligrams (mg) tablets were set up. Two glipizide tablets were placed into each day’s holding slot for P1 to take at a future date. The date on the pill bottle was 9/25/25. P1’s emergency medication setup was also reviewed and observed to have two 5 mg glipizide tablets in each slot. There was no date on the holder to indicate when they were set up. P1’s plan of care (POC) dated 5/26/25 to 7/24/25, identified a current medication list that included glipizide (a medication for diabetes to control blood sugars) 5 mg tablet, 2 tablets by mouth daily. A provider order dated 4/18/25, indicated P1 was started on glipizide 5 mg, 1 tablet by mouth daily. A provider order dated 9/25/25, indicated P1 was started on glipizide 5mg, 2 tablets by mouth daily. P1’s skilled nursing progress note dated 4/25/25, indicated P1 was started on glipizide, and glipizide was added to the current medication list. Education included to take medication as ordered. P1’s medical record indicated a letter from Mayo clinic dated 9/19/25, was received which reported a concern P1 was receiving two tablets of 5 mg glipizide and not one tablet as ordered. The letter included a current medication list which included glipizide 5mg tablet, take 1 tablet by mouth daily. The medical record lacked documentation the letter was reviewed and addressed by the facility. During an interview on 10/15/25 at 9:32 a.m., RN-A stated the agency set up P1’s medication one week at a time. There was also an emergency week set up in case there was some reason staff could not make it out that week. P1 was not to take that setup week unless advised to by the agency. RN-A was the nurse to set up P1’s emergency medication supply and it was done around a month ago. The emergency pill box contained two 5 mg tablets, which would have not been correct per the order at that time. The new bottle and order was received on 9/25/25, when a request for refill was sent to the pharmacy. During an interview on 10/15/25 at 10:26 a.m., the pharmacist stated P1 had been on one 5mg tablet of glipizide by mouth daily since the order was written on 4/18/25. There was a new order received on 9/25/25, which increased her glipizide does from one 5mg tablet to two 5mg tablets by mouth daily. During an interview on 10/15/25 at 1:07 p.m., the administrator stated all medications on the current medication list and used to set up weekly medications should match what the provider order states. If one tablet is all that is ordered, then only one tablet should be placed in each holding slot for the med setup. If there are discrepancies between the orders, the current medication list or what is on the bottle then the nurse should call the provider to clarify the correct order and follow the correct order. The administrator reviewed all of P1’s medical records and confirmed P1 should have only received one tablet of 5mg glipizide until the order was changed on 9/25/25. The administrator was unsure if anybody addressed the letter received from Mayo clinic related to the medication errors. During an interview on 10/15/25 at 1:48 p.m., the provider stated a home visit was performed and the medication errors were found at that time. My staff attempted to notify the agency by phone several times but never able to get in contact with anyone. The letter was then sent and faxed to the provider. They never did reach back out as requested. Facility policy Medication Administration dated 2/25/21, indicated a comprehensive medication assessment of all patient’s medications would be completed at admission and each recertification. The medications the client were on would be entered accurately onto the care plan.”