Gallagher Home Health Services

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on reviews of clinical records (CR) and policies, observations from home visits (HV) and interviews with the administrator and patients, the agency failed to develop a plan of care which included all the necessary medication, and treatments required by a patient for four (4) of seventeen (17) CRs reviewed. (CRs 1, 2, 7 and 9) A 7/24/25 review of Monitoring Medications policy revealed: Gallagher Home Health Services will reconcile all medications taken by the client prior to admission to home care with those ordered at the time of admission, before and after inpatient facility stays, at 60-day reassessment visits, and at the time of discharge. To prevent potential medication errors and to assure clients are receiving all prescribed and necessary medications. Medications will be reviewed with the client on each home visit to determine if other prescriptions or non-prescription drugs are being taken Findings include: During HV#1 conducted on 7/22/25 certification period 6-12-25 to 8-10-25 at approximately 10:00am the patient associated with CR2 confirmed that they were not taking Enoxaparin Sodium 40mg/0.4ml injection daily. A review of CR2’s Client Medication Report printed on 7/21/25 did note the medication Enoxaparin Sodium 40mg/0.4ml injection daily. CR2 also confirmed that they were taking MiraLAX 2 teaspoons PRN and Tramadol 2 tabs 50mg prescription label dated 4-15-25. A review of CR2’s Client Medication Report printed on 7/21/25 did not note MiraLAX 2 teaspoons as needed or Tramadol 2 tablets 50mg. The medication discrepancy was presented to the administrator on 7/25/25. On 7/25/25 it was determined during an interview with the agency administrator that the Client Medication Report did not contain and order for medications MiraLAX 2 teaspoons as needed or Tramadol 2 tablets 50mg but did contain an order Enoxaparin Sodium 40mg/0.4ml injection daily. During HV#3 conducted on 7/22/25 certification period 7-14-25 to 9-11-25 at approximately 11:48 am the patient associated with CR1 confirmed they were taking Cephalexin 500mg tablet x 10 days by mouth as per the prescription label dated 7/14/25. A review of CR1’s Client Medication Report printed on 7/21/25 did not note the medication Cephalexin 500mg tablet x10days. The medication discrepancy was presented to the administrator on 7/25/25. On 7/25/25 it was determined during an interview with the agency administrator that the Client Medication Report did not contain an order for medication Cephalexin 500mg tablet x 10 days order. During HV#7 conducted on 7/23/25 certification period from 7-1-25 to 8-29-25 at approximately 2:30pm the patient associated with CR7 confirmed they were taking Crestor 10mg 1 tablet daily and Tylenol 500mg 2 tablets every 8 hours as needed. A review of CR7’s Client Medication Report printed on 7/21/25 did not note either of the aforementioned medications. The medication discrepancy was presented to the administrator on 7/25/25. On 7/25/25 it was determined during an interview with the agency administrator that the Client Medication Report did not contain an order for medications Crestor 10mg 1 tablet daily and Tylenol 500mg 2 tablets every 8 hours as needed orders. During HV#6 conducted on 7/23/25 certification period 7-5-25 to 9-2-25 at approximately 1:50pm the patient associated with CR9 confirmed they were taking Sertraline 50mg 1 tablet twice a day and Lipitor 40mg daily. A review of CR9’s Client Medication Report printed on 7/21/25 did not note either of the aforementioned medications. The medication discrepancy was presented to the administrator on 7/25/25. On 7/25/25 it was determined during an interview with the agency administrator that the Client Medication Report did not contain an order for medications Sertraline 50mg 1 tablet twice a day and Lipitor 40mg daily.”