Phoenix Home Care

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Medication Reconciliation,” revised on 11/2019, showed, in part, the following: - Medication reconciliation is required at Start of Care (SOC) and Discharge, and at least every 60 days, and must be documented in the clinical record. Medications included shall be all prescriptions, over-the-counter and herbal supplements being taken by the patient; - Medication reconciliation shall be documented when new medications are prescribed; and - Medication review shall be conducted periodically throughout the episode of care to determine if the consumer has added or eliminated medications or herbal products from the medication regimen. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 08/06/2025 with primary diagnosis of amyotrophic lateral sclerosis (ALS; Lou Gehrig’s disease; a nervous system disease that causes loss of muscle control), pseudobulbar affect (PBA) (medical condition that causes crying and or/ laughing that is sudden, frequent, uncontrollable and is exaggerated or doesn’t match how you feel. PBA may be caused by neurological damage related to your neurological condition or brain injury but is a separate and treatable condition), cramps and spasm and history of falling. The patient resided at home with significant other and three other roommates as caregivers. Observation and interview on 09/03/2025 at 11:00 AM, showed: - The provider’s medication list had Acetyl-L-Carnitine HCl (supplement that may improve memory loss) 750 milligrams (mg) mix 750 mg in a liquid and take by mouth daily. The patient stated that he/she had been taking the medication twice a day forever; - The provider’s medication list had Alpha-Lipoic acid (supplement that provides protection to the brain and helpful in certain liver diseases) oral 600 mg one tablet by mouth daily. The patient stated that he/she took 700 mg daily; - The provider’s medication list had Ashwagandha (supplement for stress, anxiety and sleep) 500 mg take one capsule by mouth daily. The patient stated that he/she took 600 mg daily; - The provider’s medication list had Gaba powder (supplement to help with anxiety, depression and stress) one gram (gm) by mouth twice a day. The patient stated that he/she took 250 mg twice a day; - The provider’s medication list had L-Serine (supplement to recover cognitive function, improve cerebral blood flow, inhibit inflammation, promote remyelination and exert other neuroprotective effects on neurological injury) 1.5 gm take 1.5 gm twice a day. The patient stated that he/she took 7 gm twice a day; - The provider’s medication list had L-Lysine (supplement building block for making proteins in the body) 1000 mg take one tablet by mouth daily. The patient stated that he/she took 500 mg powder form twice a day; - The provider’s medication list had magnesium oxide (supplement) 400 mg take one tablet by mouth daily. The patient stated that he/she had not taken the medication for about a month and it was a different magnesium than listed; - The provider’s medication list had NAC (supplement to relieve symptoms of respiratory conditions by acting as an antioxidant and expectorant, loosening mucus in your air passageways) oral 500 mg take two capsules (1gm total) daily. The patient stated that he/she took 1 gm of powder form twice a day; - The provider’s medication list had Omega-3 Fatty acids (supplement that serve as energy for the muscles, heart, and other organs as building blocks for cell membranes and as energy storage for the body) oral 500 mg capsules, take three (1.5 gm) capsules by mouth daily. The patient stated that he/she took two daily (1000 mg) and has been since the start of care (SOC); - The provider’s medication list had Radicava ORS (antioxidant that works by neutralizing harmful molecules in the body called free radicals, which are believed to contribute to the progression of ALS) oral 105 mg/5 milliliters (ml) take 5 ml by mouth in a 14 day period times 10 days then off for 14 days. The patient stated that he/she stopped the medication around 8/15/2025 because he/she was seeing no benefit as it was a trial medication; - The patient stated that he/she used NADH (amino acid supplement to generate energy) 20 mg twice a day. The provider’s medication profile failed to include NADH; - The patient stated that he/she took Mito-Q (supplement for energy) 20 mg daily. The provider’s medication profile failed to include Mito-Q; - The patient stated that he/she took Aakg (body building supplement) 1 gm powder twice a day. The provider’s medication profile failed to include Aakg; - The patient stated that he/she took Micro Vitamin (vitamins and minerals needed by the body in very small amounts) five capsules daily with food (started about two weeks ago). The provider’s medication profile failed to include Micro Vitamin; - The patient stated that he/she took Astaxanthin (powerful antioxidant and anti-inflammatory agent, potentially improving skin health, eye health, heart health, and brain function) 12 mg capsule daily (has been on since the SOC). The provider’s medication profile failed to include Astaxanthin. During an interview on 09/04/2025, beginning at 9:50 AM, the administrator stated that all disciplines were to ask about medication changes at every visit.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to provide a completed transfer summary to the health care facility providing care to the patient within two (2) days of becoming aware of the transfer in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to adversely affect the post discharge care of all the patients served by the provider. Findings included: Review of the provider’s policy titled, “Home Health Transfer and Discharge Policy,” dated 11/2019, showed in part: - Purpose: to facilitate the proper transfer and discharge of patients from home health services; and - A completed transfer summary that is sent within two business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the home health agency (HHA) becomes aware of the transfer. RECORD/PATIENT #4: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 08/11/2025 with a primary diagnosis of acute (sudden onset) and chronic (over a long period of time) respiratory failure (a condition where there’s not enough oxygen or too much carbon dioxide in your body) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions); and - The patient resided in the home with his/her spouse. Review of the transfer summary, dated 08/16/2025, showed: - The patient was transferred to the hospital on 08/16/2025; - The transfer summary was completed by the physical therapist on 08/16/2025; and - The summary of care section showed, “medication profile to be attached to transfer summary and faxed to receiving facility and attending/following physician.” Review of the fax cover sheet showed the transfer summary was faxed to the primary care provider (PCP) on 08/22/2025. Review of the clinical record failed to show the transfer summary was sent to the receiving health care facility (hospital). During an interview on 09/04/2025 at 09:30 AM, the administrator stated that: - The transfer summary was faxed to the PCP six days after the patient’s transfer; and - He/she could not find that the transfer summary was sent to the hospital.”