Hana Care Texas

“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 observation, record review, and interview the agency failed to review all of the medications the client was currently taking as part of the patient’s comprehensive assessment for 1 of 3 Patients (Patient 3). This failure placed Clients at risk for adverse events due to the nurses not being able to adequately monitor for side effects, interactions, and effectiveness of medications, due to not having an accurate assessment of what they are on. Findings included: Record review of Patient 3’s file included the document titled, Home Health Plan of Care and Certification, date for the Certification Period of 3/6/26 to 5/4/26, revealed the following diagnoses: “Acute systolic heart failure, chronic kidney disease, anemia, unspecified dementia, cardiac arrythmias (disorders of heart rate), nonrheumatic aortic valve disorders (disease of a heart valve). Review of this document also showed an order for skilled nursing once a week for 9 weeks. Record review of Patient #3’s file included the document titled, “Medication Profile,” undated, revealed that the current medications for Patient 3 included the following: Aspirin Adult Low Dose Oral Tablet Delayed Release 81 MG (blood thinner) Atorvastatin Calcium Oral Tablet 40 MG (for cholesterol) Calmoseptine External Ointment (moisture barrier cream to protect and soothe skin) Furosemide Oral Tablet 40 MG (diuretic/water pill to help with swelling) Ketoconazole External Cream 2 % (antifungal for flaky skin) Metoprolol Succinate ER Oral Tablet (beta blocker for heart failure) Sildenafil Citrate Oral Tablet 50 MG (treats pulmonary hypertension/high pressure in lungs) Spironolactone Oral Tablet 25 MG (diuretic/water pill to help with swelling) During an observation and interview during home visit on 4/1/26 at 11:30 AM in Patient 3’s home with FM #3 and RN A, the Surveyor asked Patient 3 to see all of his medications. He stated that FM 3 handles his medications. FM 3 came into the room and Surveyor asked if she could review Patient 3’s medications with her. FM 3 brought three bottles - Levothyroxine 125 mcg oral tablet (a thyroid medication) and the Furosemide Oral tablet 40 mg, Spironolactone Oral Tablet 25mg, along with the 2 skin creams listed above. Surveyor went through all medications with FM 3 in front of RN A. The patient did not have the following medications in the home: Metoprolol, Sildenafil, Atorvastatin, or Aspirin with Patient #3’s current medications. FM 3 was a licensed pharmacist and stated she managed Patient 3’s medications (Patient 3 had dementia). Surveyor asked FM 3 if Patient 3 was taking anything else, and she stated “no, this is it.” Surveyor asked her how long Patient #3 had been taking the Levothyroxine, and she stated, “for some time.” She stated that Patient #3 had not taken the Atorvastatin for a long time, and he stopped taking the Metoprolol shortly after returning home from the hospital in January because it gave him hallucinations. FM 3 stated Patient #3 did not take aspirin because “he is a hemophiliac” (bleeding disorder). She stated that a regional doctor put Patient #3 on the aspirin, but that was before they knew he had bleeding problems and it “was never taken off his [med] list.” FM 3 stated Patient #3 was not taking sildenafil and did not think he had taken it outpatient at all. In an interview during the home visit with RN A on 4/1/26 at 12:00 PM, the Surveyor asked RN A why the medication profile for Patient #3 was not up to date. She stated it was because the medication profile had been created based on a list of medications from the patient’s PCP. The Surveyor asked if RN A had reviewed the list with the Patient#3 and /or FM 3 during visits to ensure it was accurate and she said she must have missed those. In an interview with the Administrator on 4/2/26 at 2:00 PM, the Surveyor asked what the expectation was for nurses to review and update the medication profile. She stated that they, the agency. trained nurses to check the patient’s medications at every visit and update the medication profile in their EHR and send any changes to their PCP. She stated that they also trained nursing staff to look at the medication bottles and ask the patient or family if there were any changes after the patient went to a physician appointment. The Surveyor asked who was responsible for updating the medication profile, and the Administrator stated it was the responsibility of the nurse in the home. The Surveyor asked why it was important to included medications in the comprehensive assessment of the client. The Administrator stated it was important because they sent the current medication list to the patient’s physician, so they knew what the patient was taking. She also stated that a lot of their patients didn’t even know what meds they were taking and for what reason, so the nurse needed to be able to explain that to them, why they were taking it, and ensure they took it correctly. In an interview with RN A on 4/2/26 at 4:00 PM, the Surveyor asked what she typically did on each visit when reviewing patients’ medications. She stated that she asked the patient and/or family if they took the medication correctly. The Surveyor asked if she looked at the patients’ current medications at each visit. She stated that she usually did, but said, “Not exactly for [Patient 3] because [FM 3] told me she managed his medications and she was a pharmacist.” The Surveyor asked when she first completed the initial comprehensive assessment for Patient 3, did she reconcile all the patient’s current medications. She stated that she had a medication list she had from Patient 3’s PCP that she used to input Patient 3’s medications initially, but that she did not go through and compare it to what the patient was currently taking. The Surveyor asked if she was aware of the agency’s policy on ensuring patients have an updated medication list. She stated that she was aware it was supposed to be updated at every visit. The Surveyor asked why it was important to included medications in the comprehensive assessment of the patient. She stated it was because they were caring long term for the patient’s disease and needed to ensure the patient was on the correct medications and needed to monitor them for medication side effects or interactions. Review of the agency’s policy titled, “Medication List and Monitoring,” last reviewed 12/01/2018, read in part: “I. The Agency will maintain a current, accurate list of all prescription and over-the­counter (OTC) medications taken by the client/patient. (Medication Profile) Professional clinical staff will update the medication list with any change in the medication regimen.””