All Heart Home 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, observation, and interview, the agency failed to update the medication profile for 2 of 7 (Patient #3 and #7) sampled patients observed during home visits. The findings included: 1. Review of the undated agency policy, “DRUG REGIMEN REVIEW”, revealed, “...All patients will have a drug regimen review (DRR) performed each time a comprehensive assessment is completed, and as needed to accommodate changes in the patient’s medication regimen that occur between comprehensive assessment time points. PURPOSE: To provide for assessment to identify potential or existing clinically significant medication issues, patient’s knowledge of and compliance with his/her medication regimen…Upon admission to service, and other required comprehensive assessment time points, all patients will have a thorough review of all current prescribed and over-the-counter medications the patient is currently talking…The assessing clinician will question the patient about old prescriptions that are in the home…For therapy-only patients the assessing qualified therapist will list all the patient’s medications on the medication list and document any observed clinically significant medication issues…RN [Registered Nurse] may collaborate with the assessing clinician…The drug regimen review is used to identify any clinical significant medication issues…All medications that the patient is currently taking will be listed on the patient’s plan of care…All changes in medication shall be noted in the clinical record…” 2. Review of the medical record revealed Patient #3 was admitted on 12/2/2024 with diagnoses of Hypertensive Heart Disease, Hypothyroidism, and Atrial Fibrillation. Review of the Physician Orders “HOME HEALTH CERTIFICATION AND PLAN OF CARE,” dated 12/2/2024, revealed “...Atorvastatin [medication used to lower cholesterol levels] 20 mg [milligrams] oral tablet…Daily…Sennosides-docusate [medication used to treat constipation] 8.6 m-50mg oral tablet …Daily…Xarelto [medication used to thin blood] 20 mg oral tablet…PM [after midday]...” Observations in Patient #3’s home on 6/10/2025 at 8:50 AM, revealed Patient was taking atorvastatin 40 mg one tablet daily (prescription filled on 3/14/2025), Eliquis (medication used to thin blood) 5 mg one tablet twice a day (prescription filled on 3/28/2025), and losartan (medication used to treat high blood pressure) 25 mg one tablet daily (prescription filled on 3/9/2025). Review of an “Incident Report” dated 6/10/2025, revealed “…Medications had not been reconciled with new medications added when chart reviewed today in the home. Patient had discontinued Xarelto and started Eliquis due to insurance coverage (per daughter roughly 6 weeks ago)...Patient had discontinued her stool softener…had an increase in her Atorvastatin dosage from 20 mg to 40 mg…started Losartan 25 mg daily (all per daughter roughly 6 weeks ago.) Patient stated no one from home health had looked at her bottles…” During an interview on 6/10/2025 at 8:51 AM, Patient #3 confirmed she had not taken the medication for constipation for the past 6-7 months and had not taken Xarelto in 3-4 months. Patient #3 confirmed the therapy staff do not look at her pill bottles. During an interview on 6/10/2025 at 8:52 AM, the Director of Clinical Services (DOCS) confirmed the atorvastatin dose had increased to 40 mg, Eliquis was not listed on Patient #3’s medicine list, and the sennosides-docusate remained on the medication list. The DOCS confirmed a drug regimen review should be performed at each visit and medicine list updated. 3. Review of the medical record revealed Patient #7 was admitted on 5/20/2025 with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Dominant Side. Review of the Physician Orders “HOME HEALTH CERTIFICATION AND PLAN OF CARE,” dated 5/20/2025, revealed, “...Locosamide [anticonvulsant medication used to treat seizures] 200 mg [milligrams] oral tablet...Dose...500 mg...Frequency...Twice Daily...” Observations in Patient #7’s home on 6/10/2025 at 2:00 PM, revealed Patient #7 was taking locosamide 200 mg tablet twice daily and lamotrigine (medication used to treat epilepsy and bipolar disorder) 25 mg tablet twice daily. Both medications were stored in the original pill bottle with the prescription label and in a pill planner for morning and evening doses for each day of the week. During an interview on 6/10/2025 at 2:30 PM, Patient #7’s wife stated that her son took care of the medications and would load the pill planner from the prescription bottles. Patient #7’s wife confirmed that 1 locosamide 200 mg tablet and 1 lamotrigine 25 mg tablet was in the pill planner to be taken by Patient #7 during the morning and during the evening. During an interview on 6/10/2025 at 2:35 PM, Speech Therapist #1 stated she did not check Patient #7’s medication, but the medications were supposed to be checked by physical therapy or occupational therapy.”