Commonheart Home Health

“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 maintain an accurate medication list as compared to what the patient is taking in 2 of 7 home visits conducted (Patient #11 and Patient #16) in a total of 17 patient records reviewed. Findings include: Record review of agency document “Registered Nurse (RN) Guidelines/Expectations: Medication Reconciliation” (not dated) revealed “Regulatory Expectations: Medication Profile: Must match what the patient is receiving as noted on the facility Medication Administration Record (MAR) or what the patient/caregiver has/says in the patient’s home. Admission Process: 1. Nurse will create the medication profile based on the information provided through the referral and based on the information the facility/patient provide. Thereafter: 1. Nurse will review the medication profile with the facility MAR/patient’s medication list…Document your review and specific actions taken. 2. Nurse will clarify any discrepancies with the patient’s attending physician. a. Obtain clarifying orders. b. Update medication profile or provide clarification to the facility MAR.” Record review of agency document “RN Guidelines/Expectations: Case Management Responsibilities” (not dated) revealed “4. Special: a. Medications: i. Reconciliation of medications at each visit.” Record review of Patient #11’s “Home Health Certification and Plan of Care” with start of care 07/30/2025 and certification dates 07/30/2025 to 09/27/2025 revealed “Primary diagnosis: Chronic venous hypertension with ulcer and inflammation of bilateral lower extremity. Other pertinent diagnoses: Chronic obstructive pulmonary disease (COPD) and dependence on supplemental oxygen.” Patient #11 resides in an Assisted Living Facility (ALF) Memory Care Unit. Patient #11 had Skilled Nurse (SN) visits 3 times per week by this home health agency. Record review of the home health agency’s “Medication Profile” orders for Patient #11 dated 09/29/2025 revealed “Start Date 07/30/2025: Oxygen 3 Liters aerosol. Inhale 3 Liters per minute intranasally continuous.” Record review for Patient #11 revealed a hospitalization from 08/26/2025 to 08/29/2025. Review of Patient #11’s hospital discharge orders dated 08/29/2025 revealed “Assessment/Plan: COPD- Continue home 2 Liter Nasal Cannula (NC).” SN visits did not reveal that the nurse reconciled the oxygen to update the medication profile. During an observation of SN home visit at ALF M for Patient #11 on 09/29/2025 from 1:15 PM to 2:05 PM, observed RN K complete patient assessment, cares, and discuss with ALF M staff. Observation revealed that RN K did not review or compare Patient #11’s home health agency medication list with the ALF MAR. Record review of ALF M’s MAR for Patient #11 dated 09/29/2025 revealed “Order date: 07/30/2025: Start date: 07/30/2025: Oxygen at 2 Liters per Nasal Cannula (NC) to keep oxygen saturations greater than or equal to 90% every shift.” The above findings were reviewed with Director A on 09/30/2025 at 3:15 PM. During an interview with Director A on 09/30/2025 at 4:10 PM, Director A stated “About the oxygen (for Patient #11), I spoke with RN Clinical Manager J and it looks like we didn’t reconcile that from the most recent hospital records. The nursing home list is accurate.” Record review of Patient #16’s “Home Health Certification and Plan of Care” with start of care 05/01/2025 and certification dates 08/29/2025 to 10/27/2025 revealed “Primary diagnosis: Venous insufficiency chronic peripheral. Other pertinent diagnoses: Chronic kidney disease. Medication orders: Furosemide 20 milligrams (mg) oral tablet; Take 1 tablet orally once a day. Start date: 05/01/2025.” Patient #16 resides in an ALF. Patient #16 had SN visits 2 times per week by this home health agency. Record review of SN home visit documentation on 09/16/2025 for Patient #16 revealed “Narrative Note: Mention one of medications changed per the After Visit Summary noted Lasix (Furosemide) 40 mg discontinued by Cardiologist…Medication profile updated to reflect change.” Record review of the home health agency’s “Medication Profile” orders for Patient #16 dated 09/30/2025 revealed no current orders for Furosemide. During an observation of SN home visit at ALF N for Patient #16 on 09/30/2025 from 1:05 PM to 2:05 PM, observed RN L discuss Patient #16 with ALF N nurse. Observation revealed that RN L obtained a new medication profile from ALF N nurse but did not review or compare Patient #16’s home health agency medication list with the ALF MAR. Record review of ALF N’s current MAR for Patient #16 dated 09/30/2025 revealed “Order date: 09/16/2025. Furosemide 40 mg by mouth. Take 1.5 tablets by mouth once per day.” The above findings were reviewed during an interview with Director A on 09/30/2025 at 4:10 PM. Director A stated the agency would look into the discrepancy. At 10/01/2025 at 10:43 AM, per email correspondence, RN Clinical Manager J stated, “We do not have any additional information on the Furosemide discrepancy.””