Lifeline 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 policy review, medical record review, and interview, the agency failed to update the medication profile for 4 of 5 (Patient #1, #3, #4, and #5) patients reviewed during home visits. The findings included: 1. Review of the agencies “Medication Management,” last revised 7/1/2024, revealed “...PURPOSE: To provide a process to ensure continuous monitoring of medications in the patient’s home...POLICY: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode. For patients receiving skilled nursing and therapy services, the skilled nurse is responsible for medication review and reconciliation throughout the episode. The therapist will participate by monitoring and reporting any identified medication issues or non-compliance to the Patient Care Manager. For patients receiving only therapy services, the therapist is responsible to facilitate drug regimen review and medication reconciliation throughout the episode...The physician is contacted immediately if any discrepancies between agency information and patient medications are found...” 2. Medical record review revealed Patient #1 was admitted to the agency on 5/19/2026 with diagnosis of Chron’s Disease, Chronic Kidney Disease and Anemia. Medications found in the home: a. Belbuca (helps manage pain) 450 mcg (micrograms) buccal (strip placed inside the cheek) film every 12 hours b. Duloxetine (treats depression) 60 mg (milligrams) oral daily c. Gabapentin (used to manage pain) 300 mg 2 tablets oral three times daily d. Omeprazole (used to decrease stomach acid) 20 mg 2 capsules oral daily e. Simethicone (used to treat gas and bloating) 80 mg oral as needed f. Ergocalciferol (supplement) 1,250 mcg 1 capsule oral weekly g. Zofran (used to treat nausea) 4 mg oral as needed h. Aleve (used to manage pain) 220 mg oral as needed i. Buprenorphine (used to manage pain) 20 mg/hr (hour) weekly transdermal (place on the skin) patch k. Mirtazapine (used to treat depression) 7.5 mg oral as needed l. Varenicline (used to aid in cessation of smoking) 1 mg oral as needed on Sunday During an interview on 8/17/2026 at 2:19 PM, Patient #1 stated he takes his medication and had been off Metronidazole 500 mg for the past 6 weeks. During an interview on 8/17/2026 at 2:28 PM, Registered Nurse (RN) #1 stated patients are asked every visit if they have a medication change, if they say “No” I don’t check the medication and I keep going. 3. Medical record review revealed Patient #3 was admitted to the agency on 6/18/2026 with diagnosis of Anemia, Insomnia, Asthma, and Heart Failure. Medications found in the home: a. Omeprazole (used to decrease stomach acid) 40 mg 1 capsule oral as needed b. Seroquel (used to treat sleeplessness) 100 mg 1 tablet oral at bedtime c. Mirtazapine (used to treat sleeplessness) 45 mg 1 tablet oral daily During an interview on 8/18/2026 at 9:08 AM, Pt. #3 stated no new medication has been added and has been taking the medication for months. During an interview on 8/18/2026 at 9:10 AM, Physical Therapist (PT) #1 stated the medications were not listed on the medicine list and needed updated. 4. Medical record review revealed Patient #4 was admitted to the agency on 7/13/2026 with diagnosis of Quadriplegic Cerebral Palsy, Diabetes Mellitus, and Depression. Medications found in the home: a. Omega-3 Fish Oil (supplement) 300 mg - 1,000 mg capsule oral daily b. Neomycin-Polymyxin-Hydrocort (used to treat ear infection) 3.5 mg/ml (milliliter) -10,000 unit/ml-1% (percent) Ear Solution use 3 drops in left ear twice daily c. Senna (used to soften stool) 8.6 mg 3 tablets oral as needed d. Vitamin C (supplement) 500 mg tablet take 1650 mg oral daily f. Sulforaphane (supplement) 700 mg one tablet oral twice daily g. Cefadroxil (used to treat bacterial infections) 500 mg two capsules oral twice daily h. Bromelain (supplement) 500 mg two capsules oral twice a day During an interview on 8/18/2026 at 1:45 PM, Pt. #4 confirmed his medications and stated he was not taking Diazepam, Diclofenac topical gel, Psyllium Husk, and Zinc listed on the medication report. During an interview on 8/18/2026 at 1:50 PM, Occupational Therapy (OT) #1 stated medications should be checked every visit. 5. Medical record review revealed Patient #5 was admitted to the agency on 6/4/2025 with diagnosis of Diabetes Mellitus, Foot Ulcer and Osteomyelitis. Medications found in the home: a. Amiodarone (used to treat irregular heart rhythms) 100 mg one tablet oral daily b. Gabapentin (used to manage pain) 100 mg two capsules twice a day c. Tums (used to neutralize stomach acid) 750 mg 1 tablet oral chew as needed d. Basaglar (used to lower blood sugar) Kwikpen Insulin 100 units/ml (milliliter) two Kwikpens expired on 3/20/2026 and another expired on 5/20/2026 e. Acetazolamide (used for swelling) 250 mg tablet one tablet oral daily as needed expired on 10/9/2025 During an interview on 8/18/2026 at 2:40 PM, Pt. #5 confirmed the medications in the home. During an interview on 8/18/2026 at 2:45 PM, LPN #2 stated the medications are supposed to be checked every visit, I did not look at the bottles I asked if there were any change. During an interview on 8/19/2026 at 8:45 AM, the Area Administrator stated the staff, including therapy are to look at the medication bottles and match the orders every visit, coordinate and send to the physician for any changes.”