Jamen Home Health Services 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 observation, records reviews, and interviews, the agency’s Nurse failed to review all medications the patients were 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 for 3 of 3 (Patient #1, 2, and 3) active patients visited during the survey process,. In that; LVN A failed to review and reconcile Patient #1 and #2’s medications to ensure patients’ agency medication profiles contained the same medications as the medications that the patients were actually taking at home. LVN B failed to review and reconcile all medications and update Patient #3 medication profile to ensure the medications listed on the agency medication profile matched the medications the Patient was using at the facility where he resides. This failure caused Patient #1 unnecessary nerve pain and placed other patients at risk of poor health outcomes due to agency’s Nurses not reviewing Patient medications and educating Patients and Caregivers appropriately. Findings include Patient#1 Review of Patient#1’s electronic clinical records revealed a plan of care (POC) for certification period from 06/16/2026 – 08/14/2026 that showed Patient#1 started receiving care from the agency on 06/16/2026. Review of Patient#1’s POC revealed other pertinent health information about the Patient such as: The Patient’s medical diagnoses which include Orthostatic Hypotension (A sudden decrease in a person’s blood pressure level due to sudden change in position that could cause the Patient to fall due to dizziness), Dizziness and giddiness (Giddiness refers to a sensation of lightheadedness, unsteadiness, or feeling faint, often indicating an underlying health issue rather than being a disease itself. Dizziness - a general term used to describe sensations such as feeling faint, woozy, weak, or unsteady); Type 2 Diabetes mellitus with Neuropathy (Diabetic neuropathy refers to nerve damage caused by prolonged high blood sugar levels associated with diabetes mellitus. It most commonly affects the feet, leg, and sometimes the hands. Symptoms include pain, tingling, numbness, and sensitivity to touch on the affected parts of the body), Syncope (refers to temporary loss of consciousness caused by a fall in blood pressure) and Convulsion (a sudden, violent, irregular movement of the body, caused by involuntary contraction of muscles associated especially with brain disorders such as epilepsy or seizures). The POC also contained information about orders for the different disciplines (Nursing and Physical Therapy) that were to provide services to the Patient. The Patient was to receive skilled Nursing services 3 times per week for 9 weeks while the Physical Therapist was supposed to evaluate and treat the Patient effective 06/16/2026. Observation: during home visit to Patient#1 in company of LVN A on 07/02/2026 at 10:00am, we met the Patient at the door and family member in the living room. The Patient was a 69 year old Hispanic male who was very pleasant, alert and oriented to person, place, and time. The Patient was very alert and able to express himself and his needs effectively in Spanish, but he also understood a little bit of the English language. While LVN A was performing a head-to-toe assessment on the Patient he asked if Patient was having pain anywhere in his body. The Patient replied and stated that he was having pain on his legs and feet and rated it as 4 out of 10 on pain scale rating from 0 to 10 (0 means there is pain and 10 means the worst pain ever). The Patient went on to inform LVN A that he had been having severe pain in his leg and feet in the past few days that he rated 10 out of 10. To which LVN A replied, “You remember I had told you before that whenever you have severe pain that you cannot endure you should call 911 to come take you to the hospital.” The Patient responded with a nod. The Patient also reported to the Nurse (LVN A) that he had been feeling dizzy whenever he gets up and sometimes while walking outside. LVN A told the Patient to always use his walker while ambulating. Then LVN A requested to see Patient#1’s medications. The Patient brought his medications to LVN A who sat down and reviewed the Patient’s medications with no agency’s medication profile or the patient’s POC to compare and ensure that agency medication profile contained the same medications with the correct dosages and frequencies as what the Patient was actually taking at home. After LVN A finished reviewing the Patient’s medications, the Surveyor then requested to review the Patient’s medications while reviewing the medications Surveyor noticed some discrepancies in the medications that Patient #1 was taking at home from the medications listed in agency’s medication profile for the Patient. The following are the medication discrepancies the surveyor observed during the home visit between the medications that the Patient was using at home and the medications listed in the agency’s medication profile for the patient: Gabapentin 300mg tablets (a medication commonly used to treat nerve pain and partial seizure) the prescriptions label stated the Patient was to take 1 tablet 4 times by mouth daily, but during a home visit surveyor observed that the medication bottle stated Gabapentin 600mg tablet. Take 1 tablet by mouth 4 times daily. This medication was originally first dispensed for the Patient on 12/27/2025Atorvastatin 20mg tablet (Medication used to treat high cholesterol). Take 1 tablet by mouth daily, but at home the medication bottles label reads, Atorvastatin 10mg tablet. Take 1 tablet by mouth daily. This medication was filled on 03/11/2026Metformin 500mg tablet. Take 500mg by mouth twice daily for diabetic treatment, but at home the medication bottle label reads Metformin 1000mg tablet. Take 1 tablet by mouth twice daily last filled on 03/24/2026.Carvedilol 25mg tablet. Take 25mg by mouth twice daily for heart failure, but at home the medication bottle label read Carvedilol 25mg tablet. Take 1and a half tablets by mouth with food twice daily. This medication was filled on 01/22/2026. During interview with the Patient on 07/02/2026 at 10:38am the Patient stated that he normally takes Gabapentin 600mg 1 tablet twice daily instead of 4 times daily as written on medication bottle. The Patient stated that he did not know that the medication dosage had been increased from 300mg to 600mg, and he did not know that he was supposed to take it 4 times daily. The Patient also stated that he did not realize that Metformin dosage had also increased from 500mg to 1000mg tablet, but he normally takes 1 tablet of the medication twice daily. Regarding Carvedilol 25mg tablet the Patient stated that he usually takes 1 tablet of the medication twice daily instead of 1 and a half tablets as written on the medication bottle. The Surveyor further asked if any of the agency Nurses including the Supervising Nurse that came to assess and admit him to the agency had reviewed his medications during the admission process and explained to him how to take his medications the Patient replied, “No, only the nurses at the hospital spoke to him about his medications.” During interview with the LVN A on 07/02/2026 at 10:41am, LVN A stated that according to the agency’s Medication review policy Nurses are supposed to review patients’ medications during every visit, but he had not been reviewing Patient#1’s medications during his visits as required. The Surveyor asked LVN A if he had access to the Patient medication profile or the patient’s plan of care. LVN A did not respond to the inquiry. During continued interview with LVN A on 07/02/2026 Surveyor asked how LVN A could review Patient #1’s medications without the Patient’s plan of care or medication profile to compare and ensure the agency kept an accurate list of medications that the Patient was using at home. LVN A did not respond to any of the inquiries. Patient #2 Review of Patient #2’s electronic clinical records revealed a Plan of Care for certification Period 04/09/2026 – 06/07/2026 which showed the patient’s start of care date as 04/09/2026. Review of Patient #2’s POC revealed other pertinent health information about the Patient such as: The Patient’s medical diagnoses which included: Malignant Neoplasm of the Prostate (commonly known as prostate cancer- Prostate cancer is the uncontrolled growth of cells in the prostate, a gland in the male reproductive system). Observation: during a home visit on 07/02/2026 at 12:07pm Surveyor was accompanied by LVN A. The Patient was a 75 year old Hispanic male who lived in his home with his family. The Patient was alert and oriented to person, place, time, and was able to express his thoughts and needs in fluent English. During the visit LVN A requested to see the Patient’s medications. The Patient brought his medications to LVN A to review. LVN A reviewed the Patient’s medications labels one after the other. Then the Surveyor requested to see the patient’s medications after the Nurse had finished his reviews. During the Surveyor’s review of the Patient’s medications the Surveyor noticed Patient #2 was taking Losartan 100mg tablets 1 tablet by mouth daily for treatment of high blood pressure. The medication was last refilled on 05/29/2026 and this Patient had been taking this medication since 04/10/2026, but the medication was not listed in the agency’s medication profile for the Patient. During interview with Patient #2 on 07/02/2026 at 12:21pm Patient was asked if the agency’s Nurses that visit him usually request to review his medications during home visits. The Patient replied, “No, but a man who introduced himself as a staff of the agency came yesterday evening to drop the agency booklet, and he asked me for the medications that I take every day and he wrote them in his book and left.” The Patient stated that he started taking Losartan sometime this year, but he could not remember the exact date. During interview with LVN A on 07/02/2026 at 1:12pm LVN A stated that he reviewed Patient#2’s medications during the last home visit, but the Patient did not present Losartan during that time. LVN A then told Surveyor that the Patient brought that medication to show the Surveyor maybe because the Patient knew that the Surveyor was a State employee and because the Surveyor asked the Patient to bring all the medications that he was taking. Surveyor then asked LVN A how often he requested to see Patient #2’s medications during home visits. LVN A replied that he does not review the patient’s medications during every visit as he was supposed to. Surveyor then informed LVN A that the Patient started taking Losartan on 04/10/2026 and that if he had been checking the Patient’s Medications during each visit, the Patient would have shown him the medication before the Surveyor’s visit. LVN A then stated that he reviewed Patient #2 medications during his last visit, but the Patient did not show him or inform him of Losartan. Patient3 Review of Patient#3’s electronic clinical records revealed a plan of care for certification period from 05/24/2026 – 07/22/2026 that showed that Patient started receiving services on 03/25/2026. Review of Patient#3’s POC revealed other pertinent health information about the Patient such as: The Patient’s medical diagnoses which included: Hypotension (A sudden decrease in a person’s blood pressure level that could cause the Patient to fall due to dizziness) and Acute Respiratory Failure with Hypoxia(Acute respiratory failure with hypoxia is a sudden, life-threatening condition in which the lungs fail to deliver sufficient oxygen to the blood, resulting in low oxygen levels in the tissues). Further review of the POC also contained orders for discipline and treatment and frequency of visit - the skilled Nurse was supposed to visit Patient #3 times weekly for 9 weeks. The Occupational and Physical Therapist were supposed to evaluate and treat the Patient effective 05/24/2026. Observation: during a home visit on 07/02/2026 at 2:38pm Surveyor discovered that Patient#3 resided in an assisted living facility and his medications are kept by the facility Nurses in a secured medication Cart and are dispensed to the Patient at different scheduled times of the day. During the home visit, Survey met with the facility Nurse (RN A) who was in charge of the Patient’s medications for the day and requested access to review Patient #3’s medications. During Surveyor’s review of Patient#3’s medication revealed multiple discrepancies between agency’s medication profile for Patient #3 and the actual medications that the Patient was taking at the facility. The Following were medications listed on Agency’s Medication profile for the Patient: Amiodarone 200mg oral tablet. Take 1 tablet by mouth twice daily for heart failure. Start date 05/23/2026.Aspirin 81mg chewable tablet. Take 1 tablet by mouth daily to prevent blood clots.Atorvastatin 40mg tablet. Take 1 tablet by mouth daily to reduce high cholesterol.Clopidogrel 75mg oral tablet. Take 1 tablet by mouth daily to prevent blood clot formation.Famotidine 20mg oral tablet. Take 1 tablet twice daily. Used to treat stomach acid reflux and heart burns.Folic Acid 1mg tablet. Take 1 tablet by mouth daily – Vitamin supplement.Glucagon injection 1 mg. Inject 1mg intramuscular (into the muscle layer of the skin.) as needed for low blood sugar.Lispro insulin 0-12units administer subcutaneously (under the fat layer of the skin) as needed for diabetes management.Levothyroxine 88mcg oral tablet. Take 1 tablet by mouth daily for low thyroid treatment.Metoprolol succinate 25mg tablet. Take 1 tablet by mouth daily for blood pressure treatment.Midodrine 10mg tablet. Take 1 tablet by mouth three times a day for Hypotensive treatment.Quetiapine 25mg tablets. Take 1 tablet by mouth every night. Used to treat mood disorders and can also be used as a Sleep Aid. The following are the medications that were on the agency’s medication profile that Patient was no longer using at home. Lispro insulin 0-12units administer subcutaneously (under the fat layer of the skin) as needed for diabetes management.Metoprolol succinate 25mg tablet. Take 1 tablet by mouth daily for blood pressure treatment.Glucagon injection 1 mg. Inject 1mg intramuscular used to treat low blood sugar. The following are medications the Patient was still taking, but either dosage or frequencies have changed: Amiodarone 200mg tablet. Patient was taking 1 tablet twice daily, but he is now taking 1 tablet by mouth once daily, Quetiapine 25mg tablets. The Patient was taking 1 tablet by mouth every night, but he is now taking 1 tablet by mouth twice a day. The following were medications that Patient#3 was currently taking that were not in agency’s medication profile: Magnesium Oxide 400mg tablet. Take 1 tablet by mouth daily (Mineral supplement) used to treat constipation and indigestion.Melatonin 3mg tablet. Take 1 tablet by mouth daily at bedtime as sleep Aid.Tab-A- Vite Tablet. Take 1 tablet by mouth daily vitamins.Tamsulosin HCL 0.4mg capsule. Take 1 capsule by mouth once daily for help treat urinary problems associated with enlarged Prostate in men. During interview with the facility Nurse (RN A) on 07/02/2026 at 2:48pm RN A stated that the agency Nurses do not usually come to request to review Patient #3’s medications as staff from other agencies who come to visit facility patients do. RN A was asked if the Physical Therapists who came to see Patient #3 usually request to review the Patient’s medications. RN A stated no Physical Therapists or Physical Therapist assistants had ever requested her for access to review Patient #3’s medications. During interview with the Administrator on 07/03/2026 at 3:07pm, the Administrator stated that agency’s policy was for clinical staff (Nurses and PT/OT/SP) to review and reconcile patients’ medications during every visit and update the Patients’ medication profile as needed and that all agency staff and contract staff were aware of agency’s policies. Surveyor was unable to contact the LVN B, Supervising Nurse and the Alternate Supervising Nurse for interview until exit. Review of agency’s Administrative policy titled “Medication Management” last reviewed on 01/01/2026 reads in part, “…To ensure that a competent and safe medication management system is implemented for patients/Patients by ensuring accurate assessment, monitoring and evaluation of the medication regimen and maintenance of a current patient/Patient medication list… An Agency registered nurse (RN) or other clinician qualified to perform comprehensive assessments (physical therapist (PT), occupational therapist (OT), speech-language pathologist (SLP) will be responsible for coordinating the efforts of monitoring the medication regimen.VI. Medication monitoring will include assessing medication errors and adverse reactions and immediately reporting, if applicable, to the physician or allowed practitioners and documenting any medication errors, according to the Agency protocols. Documented medication errors will be incorporated into the quality assessment and performance program (QAPI) for potential analysis and performance improvement plans… VII. The Agency will maintain a current, accurate list of all prescription and nonprescription (over-the counter (OTC) medications) taken by the patient/Patient. Qualified clinical staff will update the medication list with any changes in the medication regimen, per orders…””

“Coordinate care delivery CFR(s): 484.60(d)(4) Coordinate care delivery to meet the patient’s needs, and involve the patient, representative (if any), and caregiver(s), as appropriate, in the coordination of care activities. This Element is not met as evidenced by: Based on observation, record reviews, and interviews, the agency’s Nurse failed to coordinate care delivery to meet the patient’s needs, for 1 of 3 (Patient #2) active patients visited during the survey process. In that, LVN A failed to notify the agency Administrator or Supervising Nurse of Patient #2’s recent discharge from the hospital for a resumption of care assessment to be performed by agency’s registered Nurse and a new plan of care created for the Patient. This failure placed Patient #2 at potential risk of not having his immediate needs met which could result in poor health outcome. Findings include: During a home visit with Patient #2 on 07/02/2026 at 12:19pm the patient informed Surveyor of his recent discharge from the hospital and how LVN A had been the Nurse that has been taking care of him after his discharge from the hospital. Surveyor requested to see the Patient’s hospital discharge documents from the hospital. The patient provided the Surveyor with his recent hospital discharge documents. Review of the patient’s hospital discharged document dated 5/30/26 revealed that Patient #2 was admitted to XXXX Hospital on 05/26/2026 for Rectal bleeding and difficulty swallowing and was discharged home on 05/30/2026. Review of agency’s electronic clinical records showed no record of the Patient’s admission to the hospital or discharge from the hospital. There was also no record of a Resumption of Care assessment by a registered Nurse before LVN A started visiting the patient after his discharge from the hospital. During an observation and interview with the Patient#2 on 07/02/2026 at 12:33pm Patient #2 was asked if he notified the agency that he was admitted to the hospital. The Patient stated that he did not remember to inform the agency when he was admitted to the hospital, but he called LVN A to inform him that he was discharged from the hospital and LVN A came and visited him and has been visiting him ever since he came home from the hospital. Surveyor further inquired of the Patient if any other Nurse had visited to perform a full “head-to-toe” assessment like when he first got admitted to the agency. The Patient stated that no other nurse had visited him since his return from the hospital except LVN A. Then the Patient stated a man who introduced himself as a staff of the agency came yesterday (07/01/2026) evening to drop the agency booklet, and he asked me for the medications that I take every day and he wrote them in his book and he also dropped the agency’s folder with me. During interview with LVN A on 07/02/2026 at 12:48pm LVNA was asked what agency’s policy was for patients who went to hospital while under the agency Care and then discharged from the hospital. LVN A stated that agency’s policy was for a registered Nurse to perform a resumption of care assessment and recreate a new plan of care or update the existing plan of care for the Patient before the LVN can continue to provide care to the patient. LVN A was also asked if he informed Administrator or the Supervising Nurse to visit Patient #2 after the Patient called to inform him that he was back from the hospital. LVN A replied “No.” The Surveyor continued to ask LVN A why he did not notify the Administrator or Supervising Nurse to send a RN to assess the Patient and update the plan of care before he started seeing the Patient again. The LVN did not respond to the inquiry. During interview with Administrator on 07/03/2026 at 4:32pm the Administrator stated that the agency’s policy was to have an RN conduct a resumption of care assessment for every patient that was discharged from the hospital, so a new plan of care can be created before the LVNs can continue to visit the Patient. So, why did this policy not applied to Patient #2 who was discharged from the hospital on 05/30/2026. The Administrator stated that she was just finding out today that Patient went to the hospital and had been discharged from the hospital. The Administrator further stated that all agency’s clinicians knew the agency’s policy, and they were responsible for informing her or the Supervising Nurse about any patient that went to hospital. Furthermore, she did not know why LVN A did not inform her about Patient #2’s discharge from the hospital. Review of agency’s administrative policy titled, “Monitoring Patient/Client Care/Coordination of Care” last reviewed on 01/01/2026 read in Part, “…To ensure coordination of patient/client care and treatment… The Agency will collaborate with other organizations providing services (i.e., medical equipment, other home health agencies, out-patient clinics, etc.), the patient/client, and their representative (if applicable) to ensure appropriate coordination of care… Agency staff are expected to contact the Agency to report patient/client needs and changes…””