Riceland Home Health LLC

“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 have a list of all medications the patient was currently taking for 1 of 8 patients records reviewed. (Patient #1) Patient #1’s medication list did not include Docusate Sodium (a stool softening medication used to treat constipation). This failure could place patients at risk of medication side effects or interactions. Findings included: Record review of Patient #1’s POC dated 4/15/26- 6/13/26 indicated she was 82 years old with a SOC date of 4/15/26. Her diagnosis included Encounter for orthopedic (conditions affecting the bones or muscles) aftercare following surgical amputation (surgically cutting off a limb), congestive heart failure (condition when the heart cannot pump enough blood to meet the body’s needs), Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills), and constipation (infrequent bowel movements or difficulty passing feces). Record review of Patient #1’s Medication Profile dated 4/15/26- 6/13/26 did not include any orders for Docusate Sodium. Record review of the SN Visit Calendar for Patient #1 indicated she was seen by RN E on 4/24/26, LVN A on 4/27/26 and the Alternate Supervising Nurse on 4/29/26. Record review of the SN Visit Note for Patient #1 dated 4/27/26 indicated there were no medication changes since the last visit. Record review of the SN Visit Note for Patient #1 dated 4/29/26 indicated there were no medication changes since the last visit. During an observation and interview of a home visit on 5/5/26 at 10:30 am Patient #1 said the ALF staff administered (gave) her medication. LVN A from the home health agency reviewed the ALF medication orders with the agency medication list. LVN A confirmed the ALF medication list included an order for Docusate Sodium 100 mg every 8 hours as needed for Patient #1 dated 4/25/26. LVN A confirmed the order for Docusate Sodium was not listed on Patient #1’s current Medication Profile dated 4/15/26- 6/13/26 from the agency. LVN A said she saw Patient #1 last week but did not do the medication review last week. LVN A said she wasn’t supposed to see Patient #1 last week and then last minute ended up going out to do her wound care. LVN A said it must have slipped her mind to review the medication at that visit. During a telephone interview on 5/5/26 at 2:44 pm RN E said the nurse that went out at each visit was responsible for reviewing the patient’s medication. RN E said the medication should be reconciled (reviewed for consistency) at every visit. Attempted a telephone interview on 5/6/26 at 8:00 am with Patient #1. The call went straight to voice mail. Message left identifying surveyor and requested a call back. Attempted a telephone interview on 5/6/26 at 10:22 am with Patient #1. The call went straight to voice mail. Message left identifying surveyor and requested a call back. During a telephone interview on 5/6/26 at 12:18 pm, the Alternate Supervising Nurse said the nurse at the visit was responsible for completing the medication reconciliation (review) and updating the medication list. The Alternate Supervising Nurse said the medication list was supposed to be reviewed weekly on the visit. The Alternate Supervising Nurse said they verify the agency list against the patient list and update the agency list with any changes. The Alternate Supervising Nurse said he reviewed Patient #1’s medication with her during his visit on 4/29/26. The Alternate Supervising Nurse said Patient #1 said she did not have any medication changes. The Alternate Supervising Nurse said the patient was pretty with it. The Alternate Supervising Nurse said he did not verify the medication list with the [ALF] staff. The Alternate Supervising Nurse said it was difficult to find staff at the ALF. The Alternate Supervising Nurse said he was not aware of an order for Docusate Sodium from 4/25/26. The Alternate Supervising Nurse said the facility might have added the medication and didn’t tell the agency. The Alternate Supervising Nurse said the patient medication list should be updated to accurately reflect the medication. The Alternate Supervising Nurse said if the patient medication list was not updated the agency would be unaware to update the physician about the medication and there could be a contraindication (circumstance the medication should not be used such as an interaction with another medication) for the medication. During an interview and record review on 5/6/26 at 12:45 pm, the Alternate Administrator said the nurse at the home visit was responsible for updating the medication list. The Alternate Administrator said the medication list was supposed to reviewed and updated at every visit. The Alternate Administrator reviewed the medication profile for Patient #1 dated 4/15/26- 6/13/26 and confirmed Docusate Sodium was not listed on her medication profile. The Alternate Administrator said the Docusate Sodium should be on the patient’s medication list. The Alternate Administrator said agency staff should talk to the facility staff at every visit. The Alternate Administrator said if the patient’s medication list was not updated it could affect the patient and their outcome like compliance (taking it as ordered) with the medication. During an interview and record review on 5/6/26 at 1:30 pm, the Administrator/ Supervising Nurse said the nurses in the field that went to the homes were responsible for reviewing and updating the medication list. The Administrator/ Supervising Nurse said the medication list were supposed to be reviewed and updated at every visit. The Administrator/ Supervising Nurse said the patient was seen on 4/27/26 and 4/29/26 and the Docusate Sodium ordered on 4/25/26 should have been updated at those visits. The Administrator/ Supervising Nurse said if the medication list was not updated the patient would not be monitored for interactions or side effects. The Administrator/ Supervising Nurse said they would need to be educating the patient on dehydration so she would not end up getting dehydrated, dizzy, and falling. Record review of a Medication Administration, Monitoring and Teaching policy dated 3Q/2020 indicated “… Medication Orders and Documentation Medication records are established at time of admission and updated, as needed. The medical record will contain a current … Medication Monitoring The patient is monitored on an ongoing basis for medication effectiveness and actual or potential medication-related problems …” Record review of a Client Records policy dated 2Q/2022 indicated “… The record shall contain … current medical … data and include but not limited to the following information: … Physician/allowed practitioner orders; … Physician/practitioner orders that include medications …””