Integrity Home Health

“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 maintain a current medication list for 2 of 3 Patients for which home visits occurred (Patient 1 and Patient 2) and failed to review all the client’s medications during recertification/reassessment. This failure placed Patients at risk of undetectable adverse events due to medications. Findings included: Record review of the document titled, “Home Health Certification and Plan of Care,” dated for 2/16/26 - 4/16/26, revealed Patient 1 had a Start of Care date originally of 4/22/25, so he would have had multiple reassessment/recertifications visits since he started care. Record review of the document titled, “Episode Manager,” dated for 12/18/25 - 2/15/26, revealed a document that showed the visits Patient 1 received during that period. The visit on 2/13/26 was done by SN and labeled as a “recertification” visit. Record review of document titled “Medication Profile” dated 2/16/26 - 4/16/26, revealed that the current list of medications for Patient 1 included the following: Amiodarone HCl Oral 200 mg, 1 tab daily (treats heart arrythmias) - start date 2/24/2026 Rosuvastatin Calcium Oral 20 mg 1 tab nightly (lowers bad cholesterol) - start date 2/24/2026 Hydrocodone-acetaminophen Oral 5mg-325mg (pain medication, narcotic), Q6 hours as needed - start date 2/20/26 Amoxicillin-Pot Clavulanate Oral 975-125 mg 1 tab BID (antibiotic) - start date 10/10/2025 Warfarin Sodium Oral 2 MG 1/2 Tab(s)Daily (strong blood thinner) - start date 05/02/2025 traMADol HCl Oral 50 MG 1 Tab(s) as needed for pain (opioid pain medication) - start date 4/22/25 Tamsulosin HCl Oral 0.4 MG 1 Cap(s)nightly (treats enlarged prostate) - start date 4/22/25 Pantoprazole Sodium Oral 40 MG 1Tab(s) daily (treats reflux) - start date 4/22/25 Flonase Nasal 50 MCG/ACT See notes, 1spray each nostril daily (treats allergies) - start date 3/4/25 Senna Oral 8.6 MG 1 Tab(s) as needed for constipation - start date 3/19/24 One A Day Men 50 Plus Oral 1 Tab(s)Daily (daily multivitamin) - LS Aspirin-Low Oral 81 MG 1 Tab(s) daily (for pain/blood thinner) - LS Tylenol Extra Strength Oral 500 MG 1Tab(s) as needed for pain - LS Record review of the document titled, “Home Health Certification and Plan of Care,” dated for 12/16/25-2/13/26, revealed Patient 2 had a Start of Care date originally of 8/18/2025, so he would have had multiple reassessment/recertifications visits since he started care. Record review of the document titled, “Episode Manager,” dated for 12/16/25 - 2/13/26, revealed a document that showed the visits Patient 2 received during that period. The visit on 2/11/26 was done by SN and labeled as a “recertification” visit. Record review of document titled “Medication Profile” dated 2/16/26 - 4/16/26, revealed that the current list of medications for Patient 2 included the following: Atorvastatin Calcium Oral 20 MG 1 tablet once daily (lowers bad cholesterol) - start date 2/24/26 Meloxicam Oral 15 MG 1 Tab(s) daily (anti-inflammatory for arthritis)- start date 2/24/26 Lantus Subcutaneous 100 UNIT/ML ml 40 units q am (long acting insulin to improve blood sugar control) - start date 12/31/25 Albuterol Sulfate Inhalation 0.63 MG/3ML1 vial ml uses 1 vial in nebulizer q 6-8hours as needed for wheezing (treats asthma) - start date 12/31/25 DULoxetine HCl Oral 60 MG 1 Cap(s)Daily (treats depression/anxiety/chronic pain) - start date 10/8/25 Albuterol Sulfate HFA Inhalation 108 (90Base) MCG see notes 2 puffs as needed for SOB (treats asthma)- LS Cranberry Oral 405 MG 1 Cap(s) daily (UTI prevention) - LS Ondansetron HCl Oral 4 MG 1 Tab(s) as needed (treats nausea) - LS Stool Softener Oral 100 MG 1 Cap(s) BID (helps bowel movements) - LS Vitamin D Oral 50 MCG (2000 UT) 1Cap(s) daily - LS glipiZIDE Oral 10 MG 1 Tab(s) daily (treats diabetes) - LS Pregabalin Oral 300 MG 1 Cap(s) BID (treats pain, seizures, and spasms) - LS oxyCODONE HCl Oral 5 MG 1 Tab(s)Q12 hours (treats pain) - LS Morphine Sulfate Oral 30 MG 1 Tab(s) Q8hours one tablet (treats pain) - LS metFORMIN HCl Oral 1000 MG 1 Tab(s)BID (treats diabetes) - LS Cephalexin Oral 500 MG 2 Cap(s) daily (antibiotic)- LS Baclofen Oral 10 MG 1 Tab(s) BID (muscle relaxant)- LS In an observation and interview in the home of Patient 1 on 2/24/26 at 8:30 AM, the Surveyor observed RN A ask if Patient 1 had any changes in medications. The patient answered “no”. The Surveyor asked if she could review the patient’s current medications with the current list from the agency viewed from Electronic Health Record. The patient consented, and the surveyor went through each one of the Patient 1’s medication bottles. The Surveyor found 2 medication discrepancies, despite the patient having a recertification visit 9 days ago. The patient had medication bottles for Amiodarone 200mg. At the time the Surveyor was reviewing the Patient’s medication profile in the EHR, the medication profile had the Amiodarone dose at 400mg. In addition, at the time of review, the medication profile in the EHR did not have Rosuvastatin Calcium listed at all. The Surveyor asked Patient 1 how long he had been taking these medications. He stated he had always been taking them”. He stated he was unsure when his Amiodarone dose had changed. SN updated the EHR on her tablet at this time. Medication Profile above was saved after the visit and reflected the changes SN made after the surveyor caught these errors. This can be seen by the “start date” of 2/24/26 on the Amiodarone and Rosuvastatin Calcium. This was the date that the nurse entered them into the EHR in front of the Surveyor at the patient’s home. In an observation and interview in the home of Patient 2 on 2/24/26 at 9:30 AM, the Surveyor observed LVN B ask if Patient 2 had any changes in medications. The patient’s caregiver, FM 2, answered “no he has not”. The Surveyor asked to see Patient 2’s medication bottles, and FM 2 provided them to the Surveyor for review. The Surveyor found 2 medication discrepancies, despite the patient having a recertification visit 13 days ago. The Surveyor compared the medications to the Medication Profile on the EHR, and both Atorvastatin Calcium and Meloxicam were not on the Medication Profile. The Surveyor asked FM 2 how long Patient 2 had been on those medications. She stated, “Oh he has been on those forever.” In an interview with LVN B outside of the Patient 2’s home at 10:15 AM, the Surveyor asked how often she asked her patients if they had changes in their medications. She stated she asked them every visit, but that they do not bring out all their medication bottles for her to review, so she only knows “what they tell her”. In an interview with the SN at 1:45 PM on 2/24/26, she stated that she was responsible for supervising clinicians. She stated that all clinicians are trained to ask if there were any medication changes at each visit. She also stated that a full medication reconciliation should be done whenever a patient stated medications were changed. She stated sometimes it was difficult to keep up with medication changes because the patients may have said there were no changes when, in fact, there had been changes. The Surveyor asked if the clinicians routinely reviewed all the medication bottles with the patients to ensure they match the Medication Profile in the EHR. SN stated this was done on Start of Care and Recertification visits, and as needed if there were medication changes. SN stated that sometimes the patients were reluctant to bring out all their medication bottles for the clinicians. The Surveyor asked the SN why it is important that the agency have an up-to-date medication list for each patient. The SN stated that it is important for the agency to know what patients were taking at all times so they can monitor for side-effects and interactions. The SN stated that, for example, if a patient was taking a new dose of blood pressure medication that they were not aware of, and started having low blood pressure, they would need to know the current medications and doses to be able to monitor and prevent that and educate the patient on side effects. In an interview with the Administrator at 2:10 PM on 2/25/26, she stated that it is the agency’s policy to ensure the medication profile is up to date for each patient. The Surveyor asked the Administrator why it is important that the agency have an up-to-date medication list for each patient. She stated that they need to know what each patient is taking in order to safely care for them and assess if the medication is effecting them. Review of the agency’s policy titled Plan of Care, updated 7/30/18, revealed a document that read in part, “The individualized Plan of Care must include the following: a. All pertinent diagnoses, b. The patient’s mental, psychosocial, and cognitive status, c. The types of services, supplies, and equipment required, d. The frequency and duration of visits to be made, e. Prognosis, f. Rehabilitation potential, g. Functional limitations, h. Activities permitted, i. Nutritional requirements, j. ALL medications and treatments, k. Safety measures to protect against injury…” Review of the agency’s policy titled Medication Reconciliation, undated, revealed a document that read in part, “Agency will reconcile all medication taken by the patient prior to admission to home car with those added at the time of admission, before and after inpatient facility stated, at 60-day reassessment visits, and at the time of discharge.” Further review of the document revealed a statement that read, “9. Medications will be reviewed with the patient on each home visit to determine of other prescription or non-prescription drugs are being taken.””