Enhabit 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 complete a review of all current medications to include in the list in the clinical record for 3 of 7 Patients for which home visits occurred (Patient 1, Patient 2, and Patient 3). This failure placed patients at risk of undetectable adverse events due to medications. Findings included: Record review of document titled “Client Medication Report” dated for 1/21/26, revealed that the current list of medications for Patient 1 included the following: AMLODIPINE 5 MG TABLET daily (treats high blood pressure) ASPIRIN CHILDRENS 81 MG CHEWABLE TABLET daily (blood thinner) CEPHALEXIN 500 MG CAPSULE every 12 hours (antibiotic) CETIRIZINE 10 MG TABLET daily (antihistamine to treat allergies) DICYCLOMINE 10 MG CAPSULE 3 times daily (treats Irritable Bowel Syndorme) ELIQUIS 2.5 MG TABLET 2 times daily (blood thinner) ERGOCALCIFEROL 50,000 IU weekly (Vitamin D) FINASTERIDE 5 MG TABLET daily (treats Benign Prostatic Hyperplasia) FUROSEMIDE 20 MG TABLET daily (water pill) GABAPENTIN 100 MG CAPSULE daily (anticonvulsant - prevents seizures) LISINOPRIL 2.5 MG TABLET daily (treats high blood pressure) MELOXICAM 7.5 MG TABLET daily (anti-inflammatory, pain control) MIRALAX 17 GRAM/DOSE ORAL POWDER daily (stool softener) MUPIROCIN 2 % TOPICAL OINTMENT 2 times daily (topical (on skin) antibiotic) ROSUVASTATIN 5 MG TABLET daily (treats cholesterol) TRESIBA FLEXTOUCH U-100 INSULIN 100 UNIT/ML (3 ML) SUBCUTANEOUS PEN - 45 Units daily (insulin to treat high blood sugar) Record review of document titled “Client Medication Report” dated for 1/21/26, revealed that the current list of medications for Patient 3 included the following: ACETAMINOPHEN 300 MG-CODEINE 60 MG TABLET every 6 hours (opioid pain reliever) ACETAMINOPHEN 325 MG TABLET every 6 hours (pain reliever) AMIODARONE 200 MG TABLET 2 times daily (treat irregular heart rhythm) DOCUSATE SODIUM 100 MG TABLET 2 times daily (stool softener) ELIQUIS 2.5 MG TABLET 2 times daily (blood thinner) HYDRALAZINE 25 MG TABLET 2 times daily (treats high blood pressure) HYDROXYZINE HCL 25 MG TABLET every 8 hours (treats allergies) INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS PEN 3 times daily (treats high blood sugar) JARDIANCE 25 MG TABLET daily (improves blood sugar control) MEDIHONEY (HONEY) 100 % TOPICAL PASTE 3 times a week (honey based wound care gel) METOPROLOL TARTRATE 100 MG TABLET 2 times daily (treats high blood pressure) MULTIVITAMIN daily SENNA LAX 8.6 MG TABLET 2 times daily (stool softener) At 9:20 AM on 1/21/26, an interview and observation were conducted during a home visit at Facility 2, where Patient 1 and Patient 3 resided and received medication management. The Surveyor spent a significant amount of time with Med Tech 1 and LVN B going over Patient 1 and Patient 3’s medication lists after the home visits with the patients were completed. Med Tech 1 stated she provided medications to Patient 1 and Patient 3, so she knew what they were taking every day. She pulled up the medication profile for each patient, and the surveyor compared it to the above medication profiles from Agency 1. The medication profile in Patient 1’s Electronic Health Record (EHR) from Agency 1 did not include Diclofenac 4 grams topical, despite the fact that the patient was receiving this medication from the facility. Per Med Tech 1 and the facility medication list reviewed on site, Patient 1 was not taking the Amlodipine, Cephalexin, Dicyclomine, Meloxicam, or MiraLAX, which were on the agency medication profile. It was unknown when these medications had been discontinued. Patient 1 was also taking 300g of Gabapentin, and the Ageny medication profile had his dose as 100g. The medication profile in Patient 3’s Electronic Health Record (EHR) from Agency 1 did not include Lexapro (treats anxiety and depression) 5mg, which, according to observation of the facility’s medication list, he had been receiving since 12/14/25. Per Med Tech 1 and the facility medication list reviewed onsite, Patient 3 was not taking the Jardiance. It was unknown when the Jardiance had been discontinued. In an interview with LVN B at 9:45 AM on 1/21/26, after exiting the facility, LVN B stated that Patient 3 is a new patient for her and she was just covering for another nurse who is on leave. She stated that she first saw him 2 days ago and Med Tech 1 told her there were no changes in his medications, but that they did not go over them in detail. She stated she saw Patient 1 every day, and she asked if there were any changes with his medications and the Med Tech 1 told her “no” everyday. LVN B stated that when she knew Patient 1 went to the doctor, she spoke with his family member, and if there were any new prescriptions, the family member was supposed to leave those orders out for her when she came, but that sometimes she does not do this. LVN B stated that they (the nurses) do rely on the Med Tech to alert them to any changes in the patients’ medications because the patients do not manage their own medications. Record review of document titled “Client Medication Report” dated for 1/21/26, revealed that the current list of medications for Patient 2 included the following: AMLODIPINE 10 MG TABLET bedtime - treats high blood pressure DOCUSATE SODIUM 100 MG TABLET 2 time daily - stool softener FLUVASTATIN ER 80 MG TABLET, EXTENDED RELEASE 24 HR bedtime - lowers cholesterol MEMANTINE 10 MG TABLET daily - treats Alzheimer’s MIRTAZAPINE 7.5 MG TABLET daily (antidepressant) OLMESARTAN 20 MG TABLET daily (trats high blood pressure) POLYETHYLENE GLYCOL 3350 17 GRAM ORAL POWDER PACKET every 8 hours (stool softener) QUETIAPINE 50 MG TABLET bedtime (treats depression and mood disorders) QUETIAPINE 50 MG TABLET daily (treats depression and mood disorders) TERAZOSIN 10 MG CAPSULE daily (treats high blood pressure) TIMOLOL MALEATE 0.5 % EYE DROPS (treats glaucoma) TYLENOL 325 MG CAPSULE every 6 hour (treats pain) VITAMIN D2 1,250 MCG (50,000 UNIT) CAPSULE 2 times a week (treats Vit. D deficiency) At 10:00 AM on 1/21/26, an interview and observation were conducted at Facility 2, where Patient 2 resided and received medication management. With Med Tech 2 and LVN B present, the Surveyor compared Patient 2’s medication profile from Agency 1 (above) to the medication list provided by Med Tech 2 and Facility 2. Cyanocobalamin 100mcg had been administered by the facility daily since 8/19/25 and was not on the agency medication profile. Med Tech 2 confirmed she had been administering that medication to Patient 2 since August. LVN B stated she was not aware that Patient 2 was taking this medication. In an interview with LVN B at 11:00am after exiting Facility 2, she stated that Patient 2 was regular patient of hers, but that she usually just asked the Med Tech if there were any changes, and they told her “no”. Surveyor asked why it is important that the agency has an up-to-date medication list for each patient. LVN B stated that it is important because they (the nurses) are responsible for educating the patient on their medications and assessing side effects, which they cannot do if they are not aware of the patients’ current medications. In an interview with the Administrator on 1/22/26 at 3:30 PM, she stated that they train their staff to only do a full medication reconciliation during initial assessments and recertifications, and not on every visit. She stated they are expected to ask if there are any changes in the patient’s medications, and if the patient does not manage their own medications, as was the case for these 3 patients in assisted living facilities, then they do rely on the facilities to communicate changes in the patients’ medications to them. The Surveyor pointed out that this process did not seem to be working in Facility 1 or Facility 2, as the medication technician had told the nurses there were no changes in the medications, when there clearly had been changes since the last medication reconciliation had been completed. The Administrator agreed this was a problem and stated that they were aware of this issue and were working on it in their performance improvement project. The Surveyor asked how not having updated medication lists for each patient, or not being aware of what each patient was/was not taking, could affect patient care. The Administrator stated that it was important to know the patient’s current medications to ensure that the patient is safe and that they are following physician orders. She stated, “our lists don’t matter if it’s not what the physician is expecting the patient to get.” She stated that they wanted to verify changes in medication to make sure the patients are getting what they need to help them meet their goals. The Administrator also stated they needed to have an updated medication list so that nurses would be aware of what the patient is taking and could assess for interactions and side effects, as well as provide education. Record review of agency policies revealed a document titled, “Medications,” last revised 3/31/25, which read in part, “The clinical record includes appropriate physician orders for all medications prescribed by the physician for the patient including medicated dressings and for all OTC medications, automatic stop for mediations with a discontinuation date, applicable titrating or tapering instructions. Orders for medications include: effective date of addition or change, name of medication, dose, route, frequency of administration, indications or reason for medication administration…” Further review of the above policy revealed the following statement: “If the physician prescribes or changes a mediation for self-administration during the certification period, the label on the prescription bottle constitutes that pharmacist’s transcription or documentation of the order. Staff do not need to obtain a physician’s order unless staff will administer the medication or have reason to question it…Staff will note the medication in the clinical record…Staff assesses all medication a patient may be taking to identify possible ineffective drug therapy or adverse reactions, significant side effects, drug allergies and contraindicated medication.” Further review of the document revealed the following: “Staff will assess every visit and document assessment on visit note. Staff documents all medications the patient may take on the medication profile.” Record review of agency policies revealed a document titled, “Clinical Records,” last revised 1/20/26, which read in part, “3.2 The Clinical record includes essential components…Significant history and/or medical information including diagnoses, medications, allergies, treatments, etc.””