Choice Health at Home

“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 interview, and record review the agency failed to ensure all medications currently used by the Patient were reviewed by a skilled professional for 2 of 7 active Patients whose records were reviewed (Patient #3, #7) in that: The agency did not perform a drug regimen review that accurately reflected all the medications Patient #3 and Patient #7 were currently taking. RN-A failed to accurately review medications for certification period from 11/09/2025-01/07/2026 for Patient #3 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included orders for anti-diabetic medication (medication that controls blood sugar). RN-A failed to accurately review medications for certification period from 10/26/2025-12/24/2025 for Patient #7 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included orders for anti-coagulation medication (medication to prevent blood clots). This failure could place Patients at risk of not receiving medications as ordered, deterioration, failure to improve or maintain health and staff not identifying any potential adverse effects and drug reactions, or duplicate drug therapy. Findings included: Patient #3 Review of active Patient #3 electronic medical record (EMR) , revealed an agency document titled “ Home Health Certification and Plan of Care” with orders for skilled nursing services with Start of Care date 09/10/2025 with current certification period from 11/09/2025-01/07/2026 with primary diagnosis of Frontotemporal neurocognitive disorder ( the progressive degeneration of the brain’s frontal and temporal lobes, which presents as a behavioral or language disorder with gradual onset), and Type 2 diabetes mellitus without complications (type 2 diabetes mellitus(T2DM) refers to high blood sugar levels, these blood vessels can swell, leak, or close, leading to changes that can affect vision). Further review of the POC revealed orders for skilled nursing (SN) two visits in 60 days, and 2 additional prn visits for falls, wounds, pain, mental status changes, signs and symptoms of infection, blood sugar or cardiopulmonary complication. SN to review medications every visit and instruct Patient/ caregiver on new/ changed medication regimen dose, indications, side effects, and interactions. Record review of active Patient #3 on 12/03/2025, agency document titled, “Medication Profile” dated 11/09/2025- 01/07/2026, revealed the following medications: Zyrtec allergy orally 10mg 1 tablet daily ( used to treat seasonal allergies), amlodipine besylate orally 5mg 1 tablet taken in the morning (used to treat high blood pressure), finasteride orally 5mg 1 tablet 1 time day (used to treat benign prostatic issues), desvenlafaxine succinate ER orally 50mg 1 tablet daily (used to treat major depression disorder), hydralazine hydrochloride orally 50mg 2 tablets twice daily (used to treat high blood pressure), rosuvastatin calcium orally 10mg 1 tablet daily (used to lower bad cholesterol), losartan potassium orally 100mh 1 tablet daily (used to treat the risk of stroke and high blood pressure), glimepiride orally 2mg 1 tablet once a day (lower blood sugar levels), reexulti orally 2mg 1 tablet once a day (used for major depression disorder), vitamin D2 orally 10mcg (400 unit) 1 tablet taking weekly 1 tablet (used to treat vitamin d deficiency and support bone and immune functions), simvastatin oral 40mg 1 tablet at bedtime (lower bad cholesterol and increase the good cholesterol), tamsulosin HCl oral 0.4mg 2 capsules twice daily (used to treat an enlarged prostate), and memantine HCl oral 10mg 2 tablets twice daily (used to treat moderate to severe dementia). Record review of active Patient #3 medications on hand revealed changes in 3 current medications. Patient #3 no longer takes the following medications: amlodipine besylate orally 5mg, hydralazine HCL orally 50mg, and glimepiride orally 2mg. The medication vitamin D2 orally 10mcg (400 unit), did not reveal any tablets on hand and recently been denied a refill by the Patient’s local pharmacy. Record review of RN A personnel file on 12/04/2025, revealed a hire date of 08/24/2020. An agency document titled “Job Description/ Performance Evaluation- RN.” The document was signed by RN A dated 11/03/20025. A document was revealed titled “Orientation Checklist” was signed and dated 11/03/2025 by RN A. Section- Skilled Nursing Services- Home Health Only; Medicare Coverage Criteria for Nursing Case Management, Nursing Clinical Progress note, Medication Safety/ Compliance, and Care of the Dying Patient/ Client. An additional document titled “Skilled Nursing Competency Checklist” Section 14. Clinical Skills (General)… Medication assessment and teaching was signed and dated by RN A on 11/03/2025. An agency document titled “employee Acknowledgment” read in part... Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 09/30/2027. An interview on 12/03/2025 at 12:18 pm with FM #1 revealed that Patient #3 had been on services with the agency since 09/10/2025 and that RN A has been the assigned nurse. Surveyor asked FM #1 what type of services does Patient #3 receives from the agency. FM #1 stated that the nurse comes by sometimes and checks Patients’ blood pressure and inquires if Patient #3 needed anything. FM #1 continued to say that the therapy staff came to see Patient #3. Surveyor requested to review the medication bottles of all currently taking medication. Surveyor asked FM #1 why there was not any amlodipine besylate orally 5mg, hydralazine HCL orally 50mg, glimepiride orally 2mg, and vitamin D2 orally 10mcg (400 unit) on hand. Fm #1 stated that Patient 3 no longer takes the following medications: amlodipine besylate orally 5mg, hydralazine HCL orally 50mg, and glimepiride orally 2mg. Fm #1 continued to say that the vitamin D2 orally 10mcg (400 unit) was not available because the pharmacy denied a refill due to needing a current prescription from the primary care doctor. Surveyor asked FM #1 if RN A reviewed or discussed the medications with her on the visits. FM #1 denied that RN A reviewed or discussed the medications with her. Surveyor asked did she notified RN A that there was an issue with the vitamin D2 medication. FM #1 stated that she did not. Surveyor asked why she had not notified RN A, and she replied that she did not know why. Fm #1 stated that she would take care of it with the assistance of her son if needed. An interview on 12/03/2025 at 12:46 with RN A, when she stated that she comes to do skilled nurse visits every week and she performs a comprehensive assessment each visit. Surveyor asked why the medications on hand and the agency’s document titled “Medication Profile” had significant differences. She stated that she just needed to fix it. RN A stated that she would correct the differences now. RN A continued to say that she checks the medication every week when she comes to visit the Patient. Interview with Admin/DON on 12/04/2025 at 2:45 pm, revealed that the agency policy was to perform a medication reconciliation and review with each comprehensive assessment which was every visit. The Admin/DON stated that the Admin/DON was ultimately responsible for ensuring that all the orders are correct in the Patient’s clinical record. The Admin/DON added that the admission and primary nurses have the initial responsibility of ensuring the order is correct. Admin/DON stated that she was unable to say why RN A failed to clarify the medication profile. She continued to say she did not know why RN A was unable to accurately communicate the frequency of her skilled nurse visits. The Admin/DON also stated that all nurses were expected to follow all agency policies. Patient #7 Review of active Patient #7 electronic medical record (EMR) on 12/03/2025, revealed an agency document titled “Home Health Certification and Plan of Care” with orders for skilled nursing services with Start of Care date 08/27/2025 with current certification period from 10/26/2025-12/24/2025 with primary diagnosis of Parkinson’s disorder without dyskinesia, without mention of fluctuations (a movement disorder of the nervous system that worsens over time). Further review of the POC revealed orders for skilled nursing (SN) three visits in 60 days, and 2 additional prn visits for falls, wounds, pain, mental status changes, signs and symptoms of infection, blood sugar or cardiopulmonary complication. SN to review medications every visit and instruct Patient/ caregiver on new/ changed medication regimen dose, indications, side effects, and interactions. Record review of active Patient #7 on 12/03/2025, agency document titled, “Medication Profile” dated 11/09/2025- 01/07/2026, revealed the following medications: Fosfomycin tromethamine 3gm daily (used to treat bladder infections), droxidopa 100mg three times daily (used to treat low blood pressure), carbidopa-levodopa 25-100mg three times daily (used to treat the effects of Parkinson’s disease), fluticasone furoate- vilanterol 100-25mcg one puff daily ( used to treat and manager respiratory issues), Midodrine HCL 10mg daily (used to treat low blood pressure), oxygen 2liters as needed for shortness of breath, Eliquis 2.5mg twice daily (used to prevent and treat blood clots), atorvastatin calcium 20mg daily (used to lower cholesterol and triglyceride levels), vitamin B12 100 mcg daily (used to assist with the formation of red blood cells, and nerve function), aspirin 81mg daily ( used to prevent heart attack or stroke), vitamin D3 50mcg daily (used to promote bone health and boost the immune system), and folbee plus daily (used as a multivitamin supplement to provide essential vitamins and minerals). Record review of active Patient #7 medications on hand revealed changes in that Patient #7 no longer takes the following medications: Eliquis 2.5mg twice daily, atorvastatin calcium 20mg daily, vitamin B12 100 mcg daily, aspirin 81mg daily, and vitamin D3 50mcg daily. The Midodrine HCL daily has been reduced to 5mg daily. Patient #7 medical care team has added finasteride 5mg daily, and droxidopa 300mg three times daily. Record review of RN A personnel file on 12/04/2025, revealed a hire date of 08/24/2020. An agency document titled “Job Description/ Performance Evaluation- RN.” The document was signed by RN A dated 11/03/20025. A document was revealed titled “Orientation Checklist” was signed and dated 11/03/2025 by RN A. Section- Skilled Nursing Services- Home Health Only; Medicare Coverage Criteria for Nursing Case Management, Nursing Clinical Progress note, Medication Safety/ Compliance, and Care of the Dying Patient/ Client. An additional document titled “Skilled Nursing Competency Checklist” Section 14. Clinical Skills (General)… Medication assessment and teaching was signed and dated by RN A on 11/03/2025. An agency document titled “employee Acknowledgment” read in part... Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 09/30/2027. An interview on 12/03/2025 at 2:38 pm with FM #2 revealed that Patient #7 had been on service with the agency since 08/27/2025 and that RN A has been the assigned case manager nurse. Surveyor asked FM #2 what type of services does Patient #3 receives from the agency. FM #2 stated that the nurse comes by and checks Patients’ blood pressure and other vital signs. FM #2 continued to say that the therapy staff came to see Patient #7. Surveyor requested to review the medication bottles of all currently taking medication. Surveyor asked FM #2 why there was not any Eliquis 2.5mg, atorvastatin calcium 20mg, vitamin B12 100 mcg, aspirin 81mg, and vitamin D3 50mcg and FM #2 stated that that Patient 3 no longer takes those medications. FM #2 continued to say that the Midodrine HCL daily has been reduced to 5mg daily. Also, Patient #7 medical care team has added finasteride 5mg daily, and droxidopa 300mg three times daily. Surveyor asked FM #2 did RN A review and discuss medications with her and Patient #7, FM #2 stated that RN A did not discuss medications with her at all. An interview on 12/03/2025 at 4:06 pm with RN A, when she stated that she comes to do skilled nurse visits per the schedule and she performs a comprehensive assessment each visit. Surveyor asked why the medications on hand and the agency’s document titled “Medication Profile” have significant differences she stated that she was unsure. RN A stated that she would correct the medication profile. RN A continued to say that she checks the medication every visit when she comes to visit the Patient. Interview with Admin/DON on 12/04/2025 at 2:45 pm, revealed that the agency policy was to perform a medication reconciliation and review with each comprehensive assessment which was every visit. The Admin/DON stated that the Admin/DON was ultimately responsible for ensuring that all the orders are correct in the Patient’s clinical record. The Admin/DON added that the admission and primary nurses have the initial responsibility of ensuring the order is correct. Admin/DON stated that she was unable to say why RN A failed to clarify the medication profile. She continued to say she did not know why RN A was unable to accurately communicate the frequency of her skilled nurse visits. The Admin/DON also stated that all nurses were expected to follow all agency policies. Review of agency’s policy dated 09/08/2025 and titled “Administrative Policy Manual Medication Management PC.75” pg. 1 of 8, reads in part… “Purpose: To ensure that a competent and safe medication management system is implemented for Patients/Clients…: Definition: V. A Drug regimen review I spart of the comprehensive assessment that identifies, prevents and addresses potentially clinically significant medications issues to ensure Patient/Client safety and optimize outcomes. Policy: II. The agency will ensure that assessments of a Patient/Client include a review of the medication regimen. This will include, but not limited to: H. accuracy of the medication list/ profile. Procedure: I. Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record. VII. The agency will maintain a current, accurate list of all prescription and nonprescription (over- the- counter (OTC) medications) taken by the Patient/Client. Qualified clinical staff will update the medication list with any changes in the medication regimen, per orders.” No further information was provided prior to the end of the survey.”