Adoration Home Health Brownsville

“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 3 of 5 (Patient #1, #3, and #5) patients reviewed. The findings included: 1. Review of the agencies “Medication Administration & Management,” policy last revised 10/28/2024, revealed “...The Agency will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects, contraindications and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy and non-compliance with drug therapy…The Registered Nurse (RN) or Physical Therapist, Occupational Therapist or Speech-Language Pathologist (for therapy only cases), will review all medications (both prescription and non-prescription), including nutritional supplements, vitamins and herbals, administered by any route…that the patient is currently using in order to identify any potential adverse effects or drug reactions…For accuracy and to reconcile medications across the continuum of care, a drug history will be taken during the start of care assessment and a comparison made between the physician’s orders and the current medication the patient is taking...” 2. Medical record review for Patient #1 revealed a Plan of Care (POC) dated 1/2/2025 through 3/2/2025 with a primary diagnosis of Pressure Ulcer of Left Buttock, Stage 2, Diabetes, and Hypertension. Review of the Home Health Certification and Plan of Care dated 1/2/2025 through 3/2/2025, revealed “…Arimidex [treats Breast Cancer] 1 mg [milligram]…oral…daily; Fesoterodine [extended release] [treats overactive bladder] 8 mg…oral…daily; Furosemide [removes excess fluid from the body] 40 MG…oral…daily; Novolin N…[insulin] [Diabetes]…100 units/ml [milliters]…inject 5 units under the skin every morning and night; Risperidone [Mood] 0.5 mg…oral…bedtime...” Review of Home Medication for Pt. #1: 1/2/2025 Alprazolam [antianxiety] 0.5 mg orally (by mouth) one daily as needed 1/18/2024 Potassium Chloride 10 milliEquivalent (mEq) orally two times daily 1/18/2024 Olmesartan Medoxomil [treats high blood pressure] 40 mg orally daily 12/12/2024 Hydrocortisone 2.5 % (percent) cream topically to rectum three times daily as needed Over the Counter (OTC) Magnesium 250 mg orally every day OTC Daily Fiber 1 capsule daily OTC Vitamin D3 (supplement) 50 micrograms (mcg) orally daily OTC Glucosamine Chondroitin orally every day OTC Mucinex DM (dextromethorphan) 12 hour orally as needed Novolin N…[insulin]…100 units/ml was given on a sliding scale and not as ordered Patient #1’s daughter (caregiver) confirmed Patient #1 was not taking Arimidex, Fesoterodine, Furosemide and Risperidone as ordered. In an interview during the home visit, Licensed Practical Nurse (LPN) #1 confirmed Patient #1’s medication needed reconciled, and physician needed to be contacted. 4. Review of the medical record revealed Patient #3 was admitted on 10/31/2024 with diagnoses of Congestive Heart Failure, Diabetes Mellitus, Stage 3 Chronic Kidney Disease, Morbid Obesity, Gout, and Chronic Pain. Review of the Home Health Certification and Plan of Care dated 12/30/2024 through 2/27/2025 revealed “...Alprazolam...0.5 mg... orally...bedtime; Cyproheptadine [antihistamine] 4 mg... oral... bid [2 times daily]; Insulin Glargin 15 u [units] SQ [subcutaneously] at bedtime; Vitamin D3 mcg (2,000 u) ...oral...daily...” Review of the home medications for Patient #4 revealed: 7/1/2024 Insulin Solostar (Glargine) 40 u (units) subcutaneous daily 8/13/2024 Omeprazole (treats reflux) 40 mg orally daily 11/19/2024 Oxycodone/Acetaminophen (narcotic) 5/325 mg orally as needed every 6 hours 8/14/2024 Tizanidine (muscle relaxer) 4 mg orally three times daily as needed 12/18/2024 Alprazolam 0.5 mg orally daily as needed 11/19/2024 Mag Oxide (supplement) 400 mg orally as needed 8/10/2024 Ezetimibe (treats high cholesterol) 10 mg orally every other day During an interview on 1/14/2025 at 10:15 AM, Patient #3’s daughter stated Patient #3 had not taken Vitamin D3, and Cyproheptadine since 9/2024. Also, Patient #3 was taking Insulin Solostar 40 u instead of the ordered 15 units, Omeprazole, Oxycodone/Acetaminophen, Tizanidine, Alprazolam 0.5 mg 0.5 mg daily as needed instead of at bedtime as ordered, Mag Oxide, and Ezetimibe. During an interview on 1/14/2025 at 10:40 AM, the Administrator confirmed Patient #3’s medications needed to be reconciled. 5. Review of the medical record revealed Patient #5 was admitted to the agency on 9/26/2024 with diagnoses of Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease with Heart Failure, Diabetes Mellitus, Atrial Fibrillation, Rheumatoid Arthritis, and Dependence on Oxygen. Review of the Home Health Certification and Plan of Care dated 11/25/2024 through 1/23/2025, revealed “…Lasix 40 mg…orally…2 times daily…” Review of the Home Medications revealed: Over the counter (OTC) DayQuil Severe Cold/Flu (opened) OTC Triple Antibiotic Ointment 1 oz (opened) Thera Flu Multi System Severe Cold (opened) OTC Loratadine Allergy Relief (opened) OTC Aspirin 81 (analgesic) mg x 2 bottles (opened/partially filled) OTC Allergy Relief (15 Tablets) OTC Tylenol (analgesic) 500 mg (opened/partially filled) OTC Chloreseptic Throat Spray (topical analgesic) (opened) OTC Docusate (stool softener) 100 mg (2 bubble packs) OTC Benadryl (antihistamine) 25 mg (opened/partially filled) OTC All Day Pain Relief 220 mg (opened/partially filled) OTC Allieve 220 mg (2 opened bottles/partially filled) OTC Imodium AD (antidiarrheal) 2 mg (opened/partially filled) OTC Sennoside (stool softener) 25 mg (opened/partially filled) OTC Aspirin 325 mg (opened bottle/partially filled) OTC D3 (supplement) 25 mcg OTC Zinc (supplement) 50 mg Vitamin C (supplement) 500 mg Montelukast (expectorant) 10 mg undated 10/24/2024 Sodium Chloride (electrolyte replacement) 1 gm (gram) orally every day 9/23/2024 Lasix (diuretic) 20 mg orally two times daily 10/24/2024 Omeprazole 40 mg orally every morning before breakfast 1/7/2024 Levothyroxine (treats hyperthyroidism) 0.125 mcg orally every morning Nitroglycerine [vasodilator) 0.4 mg sublingual as needed During an interview on 1/14/2025 at 1:35 PM, Patient #5 stated his Lasix was decreased in September 2024 and confirmed he did take Omeprazole, Levothyroxine, Nitroglycerin, Montelukast, OTC Dayquil, OTC Thera Flu, Loratadine, Aspirin, Allergy Relief, Tylenol, Docusate, Benedryl, All Day Pain Relief, Allieve, Immodium, Sennoside, D3, Zinc, and Vitamin C as he feels that he needs to. During an interview on 1/14/2025 at 2:15 PM, the Administrator confirmed Patient #5’s medications needed to be reconciled.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on policy review, medical record review and interview, the agency failed to ensure a discharge summary was sent to the physician or other healthcare professional responsible for care after discharge from the agency within 5 days of discharge for 1 of 4 (Patient #10) sampled discharged patients. The findings included: 1. Review of the agency’s “TRANSFER AND DISCHARGE” policy with a revision date of 4/26/2023 revealed, “...A completed discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the Agency within five (5) business days of the patient’s discharge...” 2. Medical record review for Patient #10 revealed a Start of Care date of 6/14/2024 with diagnoses which included Lymphedema, Depression, and Hypertension. The facility discharge date was 10/12/2024. There was no documentation the discharge summary was sent to the physician or other healthcare professional responsible for care. 3. During an interview on 1/15/2025 at 9:30 AM, the Administrator confirmed Pt. #10 had been discharged from services and a completed discharge summary had not been sent to the physician or other healthcare professional responsible for care.”