Saint Mary’s Home Health Care, Inc.

“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, interviews, and record review, the Home Health Agency (HHA) failed to ensure medications ordered for one of three sampled home visit patients (Patient (P) 7) accurately matched the medications in their home, thereby preventing discrepancies, duplications, omissions, changes, and/or unclear information. Findings include: Observations made during a Home Health Aide (HHA) home visit to P 7’s home on 04/08/2025 at 10:00 AM, noted that P7’s medication bottles did not match what was ordered on P7’s plan of care. The plan of care included the medication Protonix (stomach acid reducer) 40 milligrams (mg). A review of P7’s medication bottles revealed there was no bottle for Protonix. Review of P7’s Plan of Care, for certification period 03/26/25 to 05/24/25,revealed a medication order for Protonix 40 milligram (mg) tablet. The Electronic Medical Record (EMR) lacked evidence P7 and/or caregiver was ever given a medication listing/profile. During an interview with Family Member (F) 3, conducted on 04/08/5 at 10:10 AM at P7’s home, F3 confirmed there was no bottle of Protonix in the home. F3 stated, “I do not see any bottle for Protonix. P7 [identified by name] has never taken that medication and is not on it now.” When asked if F3 ever received a medication list from the HHA, F3 replied, “Not that I’m aware of.” During an interview with the Director of Professional and Clinical Services (DPCS), conducted on 04/08/25 at 1:30 PM, the DPCS stated medication reconciliation is supposed to be performed on admission and on an ongoing basis. The DPCS stated the nurse(s) or therapist(s) should look at each medication bottle at the patient’s home and reconcile it with what is ordered by the physician, thereby ensuring accuracy, and any discrepancies should be reported to the physician and updated in the EMR. The DPCS stated the patient/care giver should be provided with a copy of a medication listing/profile with those changes. Review of HHA policy titled, “Medication Reconciliation,” revised March 2018, indicated, “The Agency provides the patient and/or caregiver with written patient medication schedule/instructions, including medication name, dose, strength, route, and frequency as well as which medication will be administered by Agency staff and staff acting on behalf of the Agency . . . Medications ordered while the patient is receiving care will be compared to the medication list/profile. The medication list/profile will be updated with each new or changed medication. The patient’s medication list in the home will also be updated.””

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on record review and interview, the facility failed to ensure 1 of 8 patients (Patient (P) 2) whose records were reviewed, had complete medical records related to missing skilled nurse (SN) visit notes to evidence care was provided as directed in the plan of care (POC). Findings include: Review of P2’s electronic medical record (EMR) indicated a start of care date of 03/01/25 and a diagnosis of peritoneal abscess. Review of the POC, developed on 03/01/25, indicated the SN would visit two times a week for one week and then one time a week for seven weeks to help with care and observe the wound until seen by the surgeon. Further review of the EMR revealed telephone orders, dated 03/13/25, to cleanse wound with cleanser, pat dry with gauze, cover with new sterile gauze, and secure with an island dressing once daily. It was recorded that the patient was able to perform wound care in between SN visits. Review of the SN visits revealed no documentation for planned visits on 03/22/25, 03/29/25 and 04/05/25. On 04/08/25 at 9:38 AM, a telephone message was left for Registered Nurse (RN)1 to ask about the visits that were scheduled and not documented. RN1 did not return the call. During an interview on 04/08/25 at 10:17 AM, the Business Office Manager (BOM) was asked about the documentation for the visits. The BOM confirmed the documentation was not in the EMR. The BOM was asked how long staff had to place documentation into the EMR. The BOM stated, “Five days.” During an interview on 04/08/25 at 10:22 AM, the Director of Professional and Clinical Services (DPCS) was asked about the missing visits. The DPCS stated, “It is a constant struggle to get staff to turn in their paperwork.” The DPCS was asked how long staff had to get paperwork into the EMR. The DPCS stated, “Five days.” Review of the policy titled, “Timely Submission of Patient Documentation,” revised October 2017, revealed, “. . . The Agency will ensure the timely and proper submission of patient documentation . . . Itineraries, with all visit reports attached must be submitted the next scheduled workday, not exceeding five (5) business days. All patient visit reports from contract personnel must be submitted within five (5) business days from the date of the visit . . .””