Baptist Homecare

“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 10 patients records reviewed. (Patient #4) Patient #4’s medication list included duplicate listings of Citalopram (medication used to treat depression), Metformin (medication used to treat diabetes), Rybelsus (medication used to treat diabetes), and Simvastatin (medication used to treat high cholesterol). This failure could place patients at risk of medication errors. Findings included: Record review of Patient #4’s POC dated 4/25/26- 6/23/26 indicated she was 68 years old with a SOC date of 4/25/26. Her diagnosis included malignant neoplasm of endometrium (cancer of the inner lining of the uterus), type 2 diabetes mellitus (condition that causes persistent high levels of sugar in the blood), depression (mood disorder that causes persistent feeling of sadness and loss of interest), and hyperlipidemia (also known as high cholesterol which causes high levels of lipids or fats in the blood). Record review of Patient #4’s Medication Profile dated 4/25/26 indicated Citalopram 40 mg daily ordered on 2/15/26, Citalopram 40 mg daily ordered 4/25/26, Metformin 500 mg twice a day ordered on 2/15/26, Metformin 500 mg twice a day ordered on 4/25/26, Rybelsus 3 mg daily ordered on 2/15/26, Rybelsus 3 mg daily ordered on 4/25/26, Simvastatin 20 mg daily ordered on 2/15/26, and Simvastatin 20 mg daily ordered on 4/25/26. Record Review of Patient #4’s Medication List in her home folder dated 4/25/26- 6/23/26 indicated Citalopram 40 mg daily ordered on 2/15/26, Citalopram 40 mg daily ordered 4/25/26, Metformin 500 mg twice a day ordered on 2/15/26, Metformin 500 mg twice a day ordered on 4/25/26, Rybelsus 3 mg daily ordered on 2/15/26, Rybelsus 3 mg daily ordered on 4/25/26, Simvastatin 20 mg daily ordered on 2/15/26, and Simvastatin 20 mg daily ordered on 4/25/26. Record review of the SN Visit Calendar for Patient #4 indicated she was seen by LVN C on 5/1/26. Record review of the SN Visit Note for Patient #4 dated 5/1/26 indicated there were no medication changes since the last visit. During an observation and interview of a home visit on 5/12/26 at 2:00 pm with Patient #4 and LVN C, Patient #4 said she filled her medication planner. Patient #4 said she would sit down with the bag of medication bottles and fill her medication planner. Patient #4 said she followed the bottle [directions] for when to take the medication. LVN C reviewed the medication list in the home folder and confirmed the duplicate orders for Citalopram, Metformin, Rybelsus, and Simvastatin. LVN C reviewed the medication list in the EMR and confirmed the duplicate orders. LVN C said the medications should not be duplicated. LVN C said she was not sure why the medications were duplicated. LVN C said the first orders were prior to Patient #4 start of care for this episode so she thought it was a computer system error. LVN C said she did not notice the duplicate medications when reviewing the medications on her last visit. During an interview on 5/13/26 at 2:00 pm, the Alternate Administrator/ Alternate Supervising Nurse said all of the nurses were responsible for making sure the patient’s medication list were accurate. The Alternate Administrator/ Alternate Supervising Nurse said the medication list should be updated at every visit. The Alternate Administrator/ Alternate Supervising Nurse said the medication list should accurately reflect the medication the patient is taking. The Alternate Administrator/ Alternate Supervising Nurse said if the medication list was inaccurate the patient could take the same medication twice and double dose themselves. The Alternate Administrator/ Alternate Supervising Nurse said she was not sure why the medication was duplicated on the medication list. The Alternate Administrator/ Alternate Supervising Nurse said it might have been a system glitch. The Alternate Administrator/ Alternate Supervising Nurse said the software should not automatically pull but could pull from one episode to the next. During an interview on 5/13/26 at 2:12 pm, the Administrator/ Supervising Nurse said all of the nurses were responsible for making sure the medication list was accurate. The Administrator/ Supervising Nurse said the medication list should be updated at each visit. The Administrator/ Supervising Nurse said the medication list should be updated to accurately reflect what the patient was taking. The Administrator/ Supervising Nurse said if the patient medication list was incorrect it could cause a medication error. Record review of a Medication Management policy dated 01/02/26 indicated “Purpose To ensure that a competent and safe medication management system is implemented for patients/clients by ensuring accurate assessment, monitoring and evaluation of the medication regimen and maintenance of a current patient/client medication list. … The agency will ensure that assessment of a patient/client include a review of the medication regimen. This will include …Duplicate drug therapy … Accuracy of the medication list/profile. … Medication assessments are continuous and ongoing, occur at every scheduled clinical visit and are documented in the clinical record. … 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. The Medication Profile will also include but is not limited to: … Verification that medications listed have been reviewed to identify … duplicate drug therapy …””