Opt Home Healthcare Inc.

“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 record review, observation, and interview, the agency failed to ensure medication reconciliation was completed during the comprehensive assessment for 2 of 2 active patients. (Patients #1 & Patient #2) The assigned nurse did not identify or address expired medications present in each patient’s home. This failure placed patients at risk for adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Findings: Review of active Patient #1 electronic medical record (EMR) revealed a form titled “Home Health Certification and Plan of Care” (POC) for the period of 04/07/2025-06/05/2025, with primary diagnosis of primary hypertension (develops when blood flows through your arteries at higher-than-normal pressures), and generalized osteoarthritis (a progressive disorder of the joints caused by gradual loss of cartilage). Further review of the POC revealed orders for skilled nursing (SN) once a week for 9 weeks and physical therapy to evaluate and treat. SN to perform medication review each skilled nursing visit and reconcile medications as indicated. SN to instruct on all new and changed medications and reinforce teaching related to use of medications as part of the disease process or demonstration of knowledge deficit. During a home visit on 06/11/2025@ 12:00 P.M., Patient #1 stated that he was very compliant with his medications and had taken his medications for the day. Surveyor observed an expired bottle of Phenytoin EX (medication used to control seizures) 100mg capsules with an expiration date of 01/31/2024, and an additional medication bottled labeled Dilantin (medication used to control and prevent seizures) 100mg capsule with an expiration date of 02/24/2025 located on the living room table which Patient #1 stated was his current medications. Patient #1 stated he had taken medications from those bottles and those were the bottles he used every day. Patient #1 stated that he managed his own medications, and his provider did not assist with his medical needs. He also denied that his assigned nurse checks his medications during weekly visits. An interview with RN A on 06/11/2025 at 2:02 P.M. revealed, that he was the assigned skilled nurse for Patient #1 and he did the admission and had been his nurse since that time. RN A stated that during his weekly skilled nurse visits he performs a head-to-toe assessment, checks his medications by telling him to take his medications, check the expiration dates, and ask if there are any new medications. He stated that he was not aware of any expired mediations in the patient’s home. RN A stated that he did not think it was a big problem with expired medications and he himself sometimes took expired medications. RN A also stated that he was aware that expired medications could possibly not have the desired effect and gastric upset as the potential impact on the patient. RN A also stated that patient may have a seizure if it’s the wrong dose of medications. RN A stated that he had not communicated to the patient’s doctor about the expired medications because he was not aware of them. RN A stated that he has read and understands his job description and essential functions of his job. Patient #2 Review of active Patient #1 electronic medical record (EMR) revealed a form titled “Home Health Certification and Plan of Care” (POC) for the period of 04/24/2025-06/22/2025 with primary diagnosis of lumbar radiculopathy (a disease involving the lower back spinal nerve root) and primary hypertension (develops when blood flows through your arteries at higher-than-normal pressures). Further review of the POC revealed orders for skilled nursing (SN) once a week for 8 weeks and physical therapy once a week for 8 weeks. SN to perform medication review each skilled nursing visit and reconcile medications as indicated. SN to instruct on all new and changed medications and reinforce teaching related to use of medications as part of the disease process or demonstration of knowledge deficit. During a home visit on 06/11/2025 @ 2:20 P.M., Patient #2 stated that she was very compliant with her medications and had taken her medications for the day. Patient #2was observed to have an expired bottle of Furosemide (medication used to treat conditions involving excess fluid in the body and high blood pressure) 20 mg, with directions to take 2 tablets every day with an expiration date of 03/13/2025. The furosemide was in the bag of current medications that Patient #2 gave to the Surveyor. Patient #2 stated she had not taken medications from that bottle because she only takes them when her nurse tells her to. She stated that sometimes she had lower extremity swelling and needed to get rid of some fluid. Patient #2 also stated that her doctor had given her those instructions as well. Patient #2 stated that she had taken medications from that bottle within the last few weeks because RN A instructed her to do so but was unsure of the exact date. She stated that her assigned nurse checked her medications during weekly visits. An interview with RN A on 06/11/2025 at 2:45 P.M. revealed, that he was the assigned skilled nurse for Patient #2, and he did the admission and had been her nurse since that time. RN A stated that during his weekly skilled nurse visits he performs a head-to-toe assessment, checks her medications by telling her to take her medications, checks the expiration dates, and ask if there are any new medications. He stated that he was not aware of any expired mediations in the patient’s home. RN A stated that he thought he had checked the medications. Surveyor asked RN A if he had instructed her to take the furosemide. RN A stated that he had but also was unsure of the exact date, but it was recently. RN A stated that he did not think it was a big problem with expired medications and he himself was a doctor by profession in the Philippines and he knows that the medications would not harm Patient #2. RN A stated that he knows that the Patient #2 can take medications that had expired up to 2-3 months without any problems. Surveyor asked RN A if he has communicated with Patient #2’s doctor regarding the change in instructions. RN A stated that he communicated with the doctor regarding the order change to as needed. RN A was unable to provide Surveyor with any documentation of communication between himself and Patient #2’s doctor. RN A denied being a doctor here in Texas at this time. RN A also stated that he was aware that expired medications could possibly not have the desired effect and gastric upset. RN A stated that he had not communicated to the patient’s doctor about the expired medications because he was not aware of them. RN A stated that he has read and understands his job description. Record review of RN A personnel file revealed that he had a date of hire of 10/13/2017. An agency document titled, “Job Description/ Performance Evaluation- Registered Nurse.” The document was signed by the RN A on 10132027. RN A personnel file revealed a license verification of his registered nurse licensure with an expiration date of 07/31/2025. Record review of DON personnel file, an agency document titled, “Job Description/ Performance Evaluation-Supervising Nurse/ Alternate.” Supervising Nurse was circled indicating that this job description was for the Supervising Nurse. The document was signed by the DON on 02/01/2025. The DON had an original hire date of 10/13/2017, however she was promoted to the DON position as of 02/01/2025. Interview with the DON on 06/13/2025 at 1:00 pm revealed that the DON had read and understood her job description and expectations of her and the nurses that report to her. Surveyor questioned how she ensured that medication reconciliation was happening with every visit. The DON stated that she reminds the nurses every so often, but they should know to perform the medication reconciliation because it is part of a comprehensive assessment which should happen every visit. She stated that the RN who performs the admission they are reminded that it is the agency’s policy to perform medication reconciliation and to check the medications on hand. The DON stated again that she did not know why the nurse did not follow the agency’s clinical policies. The DON was unable to provide the Surveyor with any documentation between the agency and Patient #1 or #2’s doctor related to expired medications or changes in medications. Surveyor asked what the potential impact to the patients could be. DON stated that the patients could receive ineffective medications and not receive the intended treatment. Record review of Admin personnel file, an agency document titled, “Job Description/ Performance Evaluation-Administrator/ Alternate.” Administrator was circled indicating that this job description was for the Administrator. The document was signed by the Admin on 04/03/2017. The Admin had an original hire date of 05/21/2007, however she was promoted to the Administrator position as of 04/03/2017. Most recent job evaluation was signed and dated by the Admin on 04/01/2025. Interview with Admin on 06/13/2025 at 1:30 P.M. revealed that the Admin was not sure why RN A was not performing medication reconciliation on each visit as the POC indicated. He stated that he was unsure why RN A thought it was not a problem for the Patient ##1 to take expired medications. He stated that RN A is not representing the policies of the agency, and he was expected to follow all policies and procedures and did not receive any type of exemptions. Admin stated that he did not know why RN A was not following the agency’s policies. Admin also stated that he was not sure why the DON failed to ensure that Patient #1’or Patient #2’s POC was not being followed. Surveyor asked what the potential impact on the patients could be. The Admin stated that the patients could not be receiving the intended treatment or spoiled medications. Review of agency’s updated policy manual with a revision date of 05/02/2024 and titled “Administrative Policy Manual – Home Care Medication List and Monitoring” PC.80 pg. 1 of 2, reads in part… “Purpose: To outline a process for ongoing medication monitoring. Policy: Assessments of a patient’s /client’s response to the medication regimen are used when evaluating the continuation of the medication regimen, evaluating the patient’s/ client’s compliance, and/or identifying problems. Procedure: V. The RN, assessing clinician, or qualified clinician identified by agency policy, will monitor medications, for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy.” No additional information was provided by the end of survey on 06/13/2025.”