Accentcare Health of Pennsylvania

“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, clinical records (CR), and an interview with agency staff, the agency failed to provide documentation showing staff completed evaluations of all patient medications per policy including but not limited to: any potential adverse effects, any drug reactions including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy three (3) of seventeen (17) clinical records reviewed. (CR#3, CR#6 and CR#7). Findings include: Review of agency policy #16.05 titled ‘Medication Reconciliation’ on June 5, 2026, at approximately 8:30 AM stated, “Procedure: 2. During the visit, the clinician will review the medication list from healthcare provider and/or EMR (electronic medical record) comparing with the medications available in the home... Routine visit medication assessment: 1. On each visit, ask the patient: 2. Has the doctor made any changes to your medications? a. Have you changed the meds you are taking? Over-the-counter meds? Vitamins? Supplements? ... DOCUMENT according to agency policy: 1. Document in the patient’s record: a. Any discrepancies noted during medication reconciliation and action taken. b. Health care provider orders for medications, as needed. c. Communication with health care provider and how issue was resolved. d. Instructions given to patient/caregiver; comprehension. 2. Adjust the plan of care as appropriate and communicate changes per agency policy.” Review of agency policy #HH2.2.06 titled ‘Medication Review and Reporting of Findings’ on June 5, 2026, at approximately 8:15 AM stated, “Procedures: 1. As part of the comprehensive assessment process at admission or resumption of care, the qualified clinician completes a Medication Profile for every patient... Carefully compare the medication list from the discharging facility or health care provider to the drugs found in the patient’s home... 6. During each home visit, the skilled nurse or therapist reviews the patient’s medication regimen and looks for new, discontinued/changed medications or non-adherence... 9. The Medication Profile is updated when there is a reported change to reflect current medications, new and/or discontinued medications. To ensure the physician or allowed practitioner’s orders match the medication profile...” A review of CRs was conducted on June 3, 2026, from approximately 2:30 PM to 3:30 PM, and June 4, 2026, from approximately 8:30 AM to 2:30 PM revealed the following: CR #6, HV#6, SOC April 29, 2026. The ‘Client Medication Report’ and the ‘Home Health Certification and Plan of Care (POC) contained an order for Arthritis 10% Topical Cream daily (for joint swelling/pain), apply thin layer to skin to knees and ankles. The patient reported to the Physical Therapist PF#7, that she had been taking “ibuprofen for right leg pain. She reported taking three (3) pills but was not sure of the dosage. Ibuprofen was not included on the POC or the Clients Medication Report. There was no documentation notifying the physician or updates to the medication profile to include an order for Ibuprofen with dosage and frequency. CR# HV#7, SOC May 12, 2026. During the HV conducted on June 3, 2026, at the patient’s private residence, observed the Registered Nurse (RN) PF#6 review the patients medication list. The RN read from the medication list and did not compare the medication list to the medication containers in the home. The patient reported taking herbal medications and Metamucil. There was no documentation notifying the physician or updates made to the medication profile. An interview with the agency Administrator, Alternate Administrator, clinical and administrative staff on June 5, 2026, at 10:00 AM confirmed the above findings. Findings include: Review of agency policy #16.05 titled ‘Medication Reconciliation’ on June 5, 2026, at approximately 8:30 AM stated, “Procedure: 2. During the visit, the clinician will review the medication list from healthcare provider and/or EMR (electronic medical record) comparing with the medications available in the home... Routine visit medication assessment: 1. On each visit, ask the patient: 2. Has the doctor made any changes to your medications? a. Have you changed the meds you are taking? Over-the-counter meds? Vitamins? Supplements? ... DOCUMENT according to agency policy: 1. Document in the patient’s record: a. Any discrepancies noted during medication reconciliation and action taken. b. Health care provider orders for medications, as needed. c. Communication with health care provider and how issue was resolved. d. Instructions given to patient/caregiver; comprehension. 2. Adjust the plan of care as appropriate and communicate changes per agency policy.” Review of agency policy #HH2.2.06 titled ‘Medication Review and Reporting of Findings’ on June 5, 2026, at approximately 8:15 AM stated, “Procedures: 1. As part of the comprehensive assessment process at admission or resumption of care, the qualified clinician completes a Medication Profile for every patient... Carefully compare the medication list from the discharging facility or health care provider to the drugs found in the patient’s home... 6. During each home visit, the skilled nurse or therapist reviews the patient’s medication regimen and looks for new, discontinued/changed medications or non-adherence... 9. The Medication Profile is updated when there is a reported change to reflect current medications, new and/or discontinued medications. To ensure the physician or allowed practitioner’s orders match the medication profile...” A review of CRs was conducted on June 3, 2026, from approximately 2:30 PM to 3:30 PM, and June 4, 2026, from approximately 8:30 AM to 2:30 PM revealed the following: CR #3, HV (home visit) #4, SOC (start of care) May 21, 2026. The ‘Client Medication Report’ and the ‘Home Health Certification and Plan of Care’ (POC) contained orders for Eliquis (for blood clot prevention) 2.5 mg (milligrams) tablet, two (2) times per day by mouth, and Salonpas (lidocaine) 4% topical patch (for pain relief), apply to low back pain daily and remove in twelve (12) hours. There was no ‘Medication Profile’ present in the agency folder. The patient stated that the cardiologist instructed the patient to discontinue use of the Eliquis upon discharge to home. The patient stated that the Salonpas was only used while in the hospital for low back pain due to the bed causing back discomfort. There were no orders in the EMR to discontinue the Eliquis or the Salonpas. An interview with the agency Administrator, Alternate Administrator, clinical and administrative staff on June 5, 2026, at 10:00 AM confirmed the above findings.”

“Rehab services supervised by PT, OT CFR(s): 484.75(c)(2) Rehabilitative therapy services are provided under the supervision of an occupational therapist or physical therapist that meets the requirements of §484.115(f) or (h), respectively. This Element is not met as evidenced by: Based on a review of agency policy, clinical records (CR), and an interview with agency staff, the agency failed to ensure the Physical Therapist (PT) supervised the Physical Therapist Assistant (PTA) at least every two weeks for one (1) of seventeen (17) CR reviewed. (CR#6) Findings include: Review of agency policy #HH22.03 titled ‘Clinical Supervision Guidelines-PTA’ on June 5, 2026, at approximately 8:30 AM stated, “Policy: This Agency’s provides skilled home health services under the supervision of appropriately qualified therapists, according to policy, professional standards, state and federal regulations. The Physical Therapy Assistant (PTA) provides services under the supervision...Procedure: Supervision is documented in the medical record...State Specific Regulations-PTA Supervision: Pennsylvania...The PT will supervise every 7 visits or every 14 days whichever is less...” A review of CRs was conducted on June 3, 2026, from approximately 2:30 PM to 3:30 PM, and June 4, 2026, from approximately 8:30 AM to 2:30 PM revealed the following: CR #6, HV#6, SOC April 29, 2026. Certification period April 29, 2026, to June 27, 2026. Contained documentation that the Physical Therapist Assistant (PTA) conducted a visit on May 7, 2026. The Physical Therapist PF#7 conducted a PTA supervision visit on May 28, 2026, twenty-one (21) days later. An interview with the agency Administrator, Alternate Administrator, clinical and administrative staff on June 5, 2026, at 10:00 AM confirmed the above findings.”