Still Waters Home Health Agency

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on document review and interview, the agency failed to ensure their Emergency Preparedness Plan was reviewed and updated every 2 years. The findings included: Review of the agency’s Emergency Preparedness Plan revealed the plan was last reviewed on 10/21/2022. During an interview on 4/15/2025 at 10:25 AM, the Chief Executive Officer verified the Emergency Preparedness Plan was not updated as required.”

“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 ensure an accurate Patient Medication Record for 3 of 5 (Patient #7, #8, and #9) sampled patients with home visits. The findings included: 1. Review of the agency’s “Addendum to Medication Policy due to update with...EMR [Electronic Medical Record] of [Named] Home Health Agency Medication Reconciliation Policy” effective 9/2/2024 revealed, “...The purpose of this updated policy is to ensure the accurate and consistent reconciliation of medications for patients receiving home health services...Definitions...Medication Reconciliation: The process of comparing a patient’s current medication regimen (prescriptions, over-the counter drugs, herbal supplements...) with what is actually being prescribed or administered, to identify and resolve discrepancies...Medication reconciliation will be revisited and updated at each home visit by the healthcare provider...Any changes to medications during the patient’s care...must be communicated to the interdisciplinary team and accurately documented int he patient’s EMR...” 2. Medical record review for Patient #7 revealed a Start of Care date of 3/5/2025 with diagnoses which included Fibromyalgia, Osteoarthritis, Hypertensive Heart Disease with Heart Failure, and Polyneuropathy. Observations in Patient #7’s home on 4/14/2025 at 11:15 AM, revealed the Patient was taking the following medications which were not included on the Patient Medication Record: Gabapentin (used to treat neuropathy and/or nerve pain) 600 milligrams (mg) three times a day Amlodipine (used to treat high blood pressure) 5 mg once a day Duloxetine HCL (used to treat depression) 60 mg once a day Austedo (used to treat side effects of involuntary movements caused from other medications) 12 mg 2 tablets twice daily During an interview on 4/14/2025 at 11:20 AM, Patient #7 confirmed she was taking the above medications in addition to the other medications listed on the Patient Medication Record. 3. Medical record review for Patient #8 revealed a Start of Care date of 2/11/2025 with diagnoses which included Surgical Aftercare following surgery on the digestive system, Malignant Neoplasm of Rectosigmoid Junction, Multiple Myeloma, and Nutritional Anemia. Observations in Patient #8’s home on 4/14/2025 at 10:40 AM, revealed the Patient was taking the following medication that was not included on the Patient Medication Record: Quetiapine Fumarate (used to treat psychosis, depression, and insomnia) 25 mg at bedtime Additionally, the Patient Medication Record indicated Patient #8 was taking Amitriptyline HCL (used to treat depression) 25 mg daily; however, the medication was not found in the Patient’s home. During an interview on 4/14/2025 at 10:40 AM, Patient #8 stated her physician discontinued the Amitriptyline and started the Quetiapine Fumarate about 3 months ago. 4. Medical record review for Patient #9 revealed a Start of Care date of 3/12/2025 with diagnoses which included Dementia, Depression, Heart Failure, Diabetes Mellitus, and Stage 3 Chronic Kidney Disease. Observations in Patient #9’s home on 4/14/2025 at 12:10 PM, revealed the Patient was taking the following medication that was not included on the Patient Medication Record: Loratadine (treats allergic symptoms) 10 mg orally as needed, Over the Counter (OTC) Centrum 50+ Years (multivitamin) every day, and OTC Magnesium Glycinate (supplement)1 orally every day. 5. During an interview on 4/15/2025 at 10:25 AM, the Chief Executive Officer verified the medications the patients took in the home should match the Patient Medication Record and should be reviewed and updated each home visit. Based on policy review, medical record review, observation, and interview, the agency failedto ensure an accurate Patient Medication Record for of 3 of 5 (Patient #7, #8, and #9) sampled patients with home visits. The findings included: 1. Review of the agency’s “Addendum to Medication Policy due to update with...EMR [Electronic Medical Record] of [Named] Home Health Agency Medication Reconciliation Policy” effective 9/2/2024 revealed, “...The purpose of this updated policy is to ensure the accurate and consistent reconciliation of medications for patients receiving home health services...Definitions...Medication Reconciliation: The process of comparing a patient’s current medication regimen (prescriptions, over-the counter drugs, herbal supplements...) with what is actually being prescribed or administered, to identify and resolve discrepancies...Medication reconciliation will be revisited and updated at each home visit by the healthcare provider...Any changes to medications during the patient’s care...must be communicated to the interdisciplinary team and accurately documented int he patient’s EMR...” 2. Medical record review for Patient #7 revealed a Start of Care date of 3/5/2025 with diagnoses which included Fibromyalgia, Osteoarthritis, Hypertensive Heart Disease with Heart Failure, and Polyneuropathy. Observations in Patient #7’s home on 4/14/2025 at 11:15 AM, revealed the Patient was taking the following medications which were not included on the Patient Medication Record: Gabapentin, used to treat neuropathy and/or nerve pain, 600 mg three times a day Amlodipine, used to treat high blood pressure, 5 mg once a day Duloxetine HCL, used to treat depression, 60 mg once a day Austedo, used to treat side effects of involuntary movements caused from other medications, 12 mg 2 tablets twice daily During an interview on 4/14/2025 at 11:20 AM, Patient #7 confirmed she was taking the above medications in addition to the other medications listed on the Patient Medication Record. 3. Medical record review for Patient #8 revealed a Start of Care date of 2/11/2025 with diagnoses which included Surgical Aftercare following surgery on the digestive system, Malignant Neoplasm of Rectosigmoid Junction, Multiple Myeloma, and Nutritional Anemia. Observations in Patient #8’s home on 4/14/2025 at 10:40 AM revealed the Patient was taking the following medication that was not included on the Patient Medication Record: Quetiapine Fumarate, used to treat psychosis, depression, and insomnia, 25 mg at bedtime Additionally, the Patient Medication Record indicated Patient #8 was taking Amitriptyline HCL 25 mg daily; however, the medication was not found in the Patient’s home. During an interview on 4/14/2025 at 10:40 AM, Patient #8 stated her physician discontinued the Amitriptyline and started the Quetiapine Fumarate about 3 months ago. 4. Medical record review for Patient #9 revealed a Start of Care date of 3/12/2025 with diagnoses which included Dementia, Depression, Heart Failure, Diabetes Mellitus, and Stage 3 Chronic Kidney Disease. Observations in Patient #9’s home on 4/14/2025 at 12:10 PM, revealed the Patient was taking the following medication that was not included on the Patient Medication Record: 3/5/2025 Loratadine (treats allergic symptoms) 10 mg orally as needed, Over the Counter (OTC) Centrum 50+ (supplement) years every day, and OTC Magnesium Glycinate (supplement)1 orally every day. 5. During an interview on 4/15/2025 at 10:25 AM, the Chief Executive Officer verified the medications the patient is taking in the home should match the Patient Medication Record and should be reviewed and updated each home visit.”