Resta Home Health LLC

“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, drug reactions, ineffective drug therapy, significant side effects and noncompliance for one (1) of ten (10) MR’s reviewed (MR). Findings Included: Review of the agency policy was conducted on 1/13/2026 at approximately 1:45 PM which revealed, “ Subject: MEDICATION MANAGEMENT…POLICY The agency has a medication management system that supports client safety and improves quality of care treatment and services by reducing practice variation, errors and misuse of medications. The agency has established a mechanism for identifying and reporting potential and actual errors, and a process to improve systems and performance in the area of medication administration and management…*If there are other health care organizations providing services in the home, the medication profile will be made available to them. Family members or other support individuals that may…” Review of the agency policy was conducted on 1/13/2026 at approximately 1:45 PM which revealed, “Subject: PHYSICIAN ORDERS…POLICY Home health services are provided in accordance with physician orders, except in cases where physician orders are not required by specific program/payer. The orders may be initiated via telephone, in writing, or facsimile, and must be countersigned by the physician in a timely manner. All medications and treatments, that are part of the client’s plan of care, must be ordered by the physician…PROCEDURE 1. Physician orders are accepted direct from a physician or an authorized representative acting on the physician’s behalf. Physician orders may be accepted by a registered nurse or licensed practical nurse, or qualified therapist (i.e., physical therapist, speech Language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered service…” Review of the agency policy was conducted on 1/13/2026 at approximately 1:45 PM which revealed, “Subject: CLIENT PLAN OF CARE…POLICY All home health services are furnished under a client’s plan of care that is established in collaboration with the client, the physician, and Agency staff…PROCEDURE…Developing a Plan of Care (POC)…A. The specific type of services and care to be delivered…C. The frequency and duration of the services/care; D. Disciplines involved in service/care…L. Rehabilitation potential: M. All Medications, treatments, and procedures…4. Drugs, services and treatments will be administered only as ordered by the physician. 5. Agency staff shall check all medications (prescription and non-prescription) ordered for the client to: * ensure safe medication administration *identify possible side effects, drug interactions *identify allergies *identify contraindicated medications or medications reacting with certain foods **Any problems or conflicts identified will be reported to the physician…” Review of (MR2 OBV1) was conducted on 1/9/2026 at approximately 10:40 AM which revealed, “Home Health Certification and Plan of Care” with a start of care date of 12/17/2025 and a current certification period starting 12/17/2025 and ending 2/14/2026. The primary diagnosis was “Vitamin B12 deficiency anemia, unspecified. OBV1 observation for care of MR2 was conducted on 1/12/2026 at approximately 10:36 AM. The agency Plan of Care was compared to the facilities medication administration record (MAR). The agency plan of care and medication profiled listed “Allergies: NKDA (no known drug allergies), the facility MAR (print date 1/12/2026) listed “ALLERGIES PCN…” The surveyor notified the agency staff on 1/13/2026 of the allergy listed on the facility MAR. The Home Health Certification and Plan of Care and Medication Profile was compared to the facilities “MAR.” The following three (3) medications were not listed on the on the agency plan of care or medication profile. “DOXEPIN HCL CAP 10 MG...Date Written: 23-Dec-2025...” “FLUTICASONE SPR 50 MCG...Date Written: 6-Nov-2025...” “POLYVINYL AL SOL 1.4% OP...Date Written: 22-Oct-2025...” The following two (2) medication were not listed on the on the facilities MAR. “TRAZODONE 150 1 TAB, BEDTIME, ORAL...Start 12/17/2025...” “ZINC GLUCONATE 50MG 1 TAB, DAILY, ORAL...Start 12/17/2025...” An exit interview was conducted with the administrator, director, and two (2) clinical care managers on 1/13/2026 at approximately 2:00 PM which confirmed the findings.”