University of TN Medical Center Home Care Services

“Patient refuses services CFR(s): 484.50(d)(4) The patient refuses services, or elects to be transferred or discharged; This Element is not met as evidenced by: Based on medical record review and interview, the agency failed to provide speech therapy (ST) evaluation ordered by physician for 1 patient (#14) of 17 patients reviewed. The findings include: Medical record review revealed Patient #14 was admitted to the agency on 12/9/2025 with diagnoses including Atrial Fibrillation and Other Sequelae or Cerebral Infraction. Medical record review of the Home Health Certification and Plan of Care dated 12/9/2025-2/06/2025 revealed a physician’s order for ST to complete an evaluation. Medical record review of a physician’s order dated 12/19/2025 revealed an order to reschedule the ST evaluation for the week of 12/22/2025-12/27/2025. Medical record review of a physician’s order dated 12/22/2025 revealed an order to reschedule the ST evaluation for the week of 12/22/2025 -12/29/2025. Medical record review of the patient was discharged from the agency on 01/06/2025 and never received the ST evaluation. Further review revealed no documentation the physician was notified the patient refused the ST evaluation. During an interview on 1/21/2026 at 1:30 PM, the Clinical Director confirmed the physician was not notified the patient refused the ST evaluation and never received a ST evaluation.”

“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 agency policy review, medical record review, and interviews, the agency failed to update the medication profile with new medications for patients (#1,#3, and #12) of 17 patients medications reviewed. The findings include: Review of the agency policy titled, “Monitoring Medications,” revised 7/1/2024 revealed “a drug regimen review will be performed on all patients...the skilled nurse is responsible for medication review and reconciliation throughout the episode...Compare medication list obtained from the facility...to actual medications patient is taking...Review all medications including over the counter (OTC) medications, vitamins...creams and topical ointments...” Review of the medical record revealed Patient #1 was admitted to the agency on 1/5/2026 with diagnoses including Chronic Kidney Disease, Rheumatoid Arthritis, and Dementia. Review of the Assisted Care Living Facility (ACLF) Medication Administration Record (MAR) for Patient #1 dated January 2026, revealed Baclofen (a medication used to treat pain) Oral Tablet 5 milligrams (mg) give one tablet orally with a start date of 7/16/2025, Replens Vaginal Moisturizer Gel apply OTC product to vulva daily with a start date of 10/3/2023, and Senna Plus (a medication used to treat constipation)Oral Tablet 8.6-50mg give two tablets twice daily with a start date of 8/8/2025. Review of the agency Client Medication Report for Patient #1 dated 1/5/2026 revealed the Baclofen, Replens Vaginal Moisturizer Gel, and Senna Plus had not been updated to reflect Patient #1’s current medication. Review of the medical record revealed Patient #3 was admitted to the agency on 12/30/2025 with diagnoses including Osteoarthritis, Diabetes Mellitus, and Hypertension. Review of the Assisted Care Living Facility (ACLF) Medication Administration Record (MAR) for Patient #3 dated January 2026, revealed Voltaren Arthritis Pain External Gel 1% (percent) apply to affected areas three times daily with a start date of 7/14/2025, Calmoseptine (a medication used to help protect and heel skin) External Ointment 0.44-20.6 % apply to affected areas for excoriation as a barrier cream with a start date of 2/24/2025, and Delsym (a medication used to treat cough and congestion) Oral Liquid 5-100mg/5 milliliters (ML) give 15 ML by mouth for cough and congestion with a start date of 11/21/2023. Review of the agency Client Medication Report for Patient#3 dated 12/30/2025 revealed the Voltaren Arthritis Pain External Gel, Calmoseptine External Ointment, and Delsym Oral Liquid had not been updated to reflect Patient #3’s current medication. Review of the medical record revealed Patient #12 was admitted to the agency on 1/3/2026 with diagnoses including Malignant Neoplasm of Upper Lobe, Diabetes Mellitus, and Atrial Fibrillation. Review of a Physician’s Order for Patient #12 dated 1/13/2026 revealed Lantus Solostar (a medication used to treat diabetes) U-100 Insulin 100 Unit/ml (3ml) to be discontinued on 1/13/2026. Review of the agency Client Medication Report for Patient#12 dated 1/21/2026 showed the Lantus Solostar U-100 Insulin 100 unit/ml (3 ml) had not been discontinued as ordered on 1/13/2026 to reflect Patient #12’s current medication orders. During an interview on 1/21/2026 at 3:30 PM, the Clinical Director confirmed the medication reconciliation are to be completed on each skilled nurse visit and the medication reconciliation had not been updated to reflect Patient #1, #3, and #12’s current medication orders.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on medical record review and interview, the agency failed to obtain laboratory specimens ordered by the physician for 1 patient (#10) of 17 patients reviewed and the physician was not alerted of the change. The findings include: Medical record review revealed Patient #10 was admitted to the agency on 12/8/2025 with diagnoses including Orthopedic Aftercare following Surgical Amputation and Type 2 Diabetes Mellitus with Hyperglycemia. Medical record review of a Physician’s Order for Patient #10 revealed a skilled nurse (SN) to obtain “...labs via [by way of] venipuncture week of 12/30/2025 and fax results...Magnesium level, CBC (Complete Blood Count), Lipid Panel and CMP (Complete Metabolic Panel)...” Medical record review of a SN note for Patient #10 revealed a SN visit had been completed on 1/2/2026. SN documentation showed she had not collected she laboratory specimens as ordered by the physician and the physician had not been alerted to the change in plan of care. During an interview on 1/21/2026 at 1:45 PM, the Clinical Director confirmed the labs had not been collected as ordered and the physician had not been notified.”