Punxsutawney Home Health 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 a review of agency policy, observations (OBV), medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of potential adverse effects for one (1) of five (5) patients for whom a home visit was conducted. (OBV5 MR1). Based on a review of agency policy, observations (OBV), medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile to ensure review of potential adverse effects for one (1) of five (5) patients for whom a home visit was conducted. (OBV5 MR1). Findings Included: Review of the agency policy was conducted on 1/29/2026 at approximately 11:47 AM which revealed, “Medication Regimen Review-Comprehensive…Policy: The RN will be responsible for monitoring the patient’s medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient’s care. Medication monitoring includes the patient’s perception of side effects and the effectiveness of his or her medication(s), and patient response to medication(s) by taking into account clinical information from the record, relevant lab values, clinical response, and medication profile. Procedure…2. All required comprehensive assessment will include 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 reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy…3. At the time of admission an accurate, current and complete list of all prescription and over-the-counter OTC medications, as well as herbal medications, taken by the patient will be maintained on the medication profile…b. The clinician will compare the medication list to those on the referral or other documents provided to the agency. Any discrepancies will be reconciled with the physician and documented in the clinical record…4. The clinician will ask the patient to describe or confirm any prescription medication, over the counter medication, vitamins, herbs or other supplements, as will as their perceptions about any side effects, and efficacy…16. An updated version of the medication list wll be provide in a timely manner to the patient following any changes and prior to discharge from (Agency). a. The patient will be encouraged to carry this list and share it with any caregivers who provide any follow-up care. b. Each patient will be provided with a complete list of medications that he or she is currently taking and/or will take after being discharged from the facility, as well as instructions on how and how long to take any new medications…” Review of the agency document was conducted on 1/23/2026 at approximately 10:10 AM which revealed, “Agency Medication Profile Report on 01/22/26 14:07…Medications (Category) Status, Medication, Instructions, Purpose, Start, Doctor, Last Edit…tamsulosin 0.4 mg; oral capsule, 1 tab daily, urinary retention, 10/11/25 Origin: SOC Finding, N/A Clinician…10/11/25 23:23…” A home visit was conducted for (MR1) (OBV5) on 1/28/2026 at approximately 1:11 PM the start of care was 10/11/2025 with the certification period of 12/10/2025 to 2/7/2026. The primary diagnosis was laceration without foreign body of right upper arm, subsequent encounter. During the home visit EMP3 (RN) conducted a medication reconciliation with the patient. EMP3 asked the patient about taking the medication Tamsulosin 0.4 mg 1 tablet daily. The patient was not taking Tamsulosin and did not remember the last time the medication was taken. Review of the agency document was conducted on 2/3/2026 at approximately 2:55 PM which revealed, “Skilled Nursing Visit…Start Date/Time: 01/28/26 13:13…Assess Medication *Medication: tamsulosin 0.4 mg oral capsule, Administration Administered How Incorrectly, patient was not taking medications/med not in home, Administered Per Plan No…” An exit interview was conducted with the director and clinical manager on 1/29/2026 at approximately 1:45 PM which confirmed the findings.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on review of agency policy/procedure, documentation and clinical records, and based on administrative staff interview, the agency failed to ensure written instructions regarding the medication schedule/instructions had been provided for one (1) of five (5) patients for whom a home visit was conducted. (OBV1 MR14). Based on review of agency policy/procedure, documentation and clinical records, and based on administrative staff interview, the agency failed to ensure written instructions regarding the medication schedule/instructions had been provided for one (1) of five (5) patients for whom a home visit was conducted. (OBV1 MR14). Findings included: Review of the agency policy was conducted on 1/29/2026 at approximately 11:47 AM which revealed, “Medication Regimen Review-Comprehensive…Policy: The RN will be responsible for monitoring the patient’s medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patient’s care. Medication monitoring includes the patient’s perception of side effects and the effectiveness of his or her medication(s), and patient response to medication(s) by taking into account clinical information from the record, relevant lab values, clinical response, and medication profile. Procedure…2. All required comprehensive assessment will include 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 reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy…3. At the time of admission an accurate, current and complete list of all prescription and over-the-counter OTC medications, as well as herbal medications, taken by the patient will be maintained on the medication profile…b. The clinician will compare the medication list to those on the referral or other documents provided to the agency. Any discrepancies will be reconciled with the physician and documented in the clinical record…4. The clinician will ask the patient to describe or confirm any prescription medication, over the counter medication, vitamins, herbs or other supplements, as will as their perceptions about any side effects, and efficacy…16. An updated version of the medication list will be provide in a timely manner to the patient following any changes and prior to discharge from (Agency). a. The patient will be encouraged to carry this list and share it with any caregivers who provide any follow up care. b. Each patient will be provided with a complete list of medications that he or she is currently taking and/or will take after being discharged from the facility, as well as instructions on how and how long to take any new medications…” A home visit was conducted for (MR14) (OBV1) on 1/28/2026 at approximately 9:20 AM, the start of care was 12/5/2025 with the certification period of 12/5/2025 to 2/2/2026. The primary diagnosis was strain of muscle, fascia and tendon of lower back, subsequent encounter. During the home visit the surveyor confirmed the patient folder was present. The surveyor requested from the staff member and family member present if an agency medication list was available. No documentation was available to confirm the agency medication list was provided to the patient or patient representative. An exit interview was conducted with the director and clinical manager on 1/29/2026 at approximately 1:45 PM which confirmed the findings.”