Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017035 (X3) Date Survey Completed 03/27/2025
Name of Provider or Supplier Infirmary Home Health Agency, Inc. Street Address, City, State 851 E I-65 Service Rd S, Suite 1000, Mobile, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0536 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 medical record (MR) review, agency policy and procedure, and interviews with staff, patients, and caregivers, it was determined the agency failed to ensure medications were reconciled to include all current medications and dosages. 

This deficient practice affected four of seven Home Visit (HV) patients including HV # 3, HV # 5, HV # 7, and HV # 2, and had the potential to affect all patients admitted to this agency. 

Findings include: 

Agency Policy: Monitoring Medications

Policy Number: 10.008

Revised: 7/1/24

Purpose: To provide a process to ensure continuous monitoring of medications in the patient's home.

Policy: A drug regimen review will be performed on all patients in conjunction with all comprehensive assessments. Additionally, all clinicians will participate in medication review and reconciliation throughout the episode...

Procedure: 

...a. Through a collaborative process the care team will: 

i. Compare medications patient is currently taking with medications ordered for the patient in order to identify and resolve discrepancies...

 


4. HV # 2 was admitted on 2/27/25 with diagnoses including Abscess of Liver and Malignant Neoplasm of Pancreas, Unspecified.

A review of the HHC and POC dated 2/27/25 revealed physician's order for Skilled Nurse two visits for week one and one visit per week for eight weeks.

 A HV was conducted on 3/25/25 at 3:00 PM to observe care provided by EI # 7, Registered Nurse . 

During the HV, a review of the current medications was conducted with EI # 7 and HV # 2 and compared to the Medicine List dated 3/25/25, the following discrepancies were found:

Amlodipine 5 mg tablet. One tablet PO (by mouth) daily for hypertension. HV # 2 said he/she has been off this medication for several months, at least since last July.

Ondansetron 8 mg ODT (orally disintegrating tablet). One tablet every 8 hours/PRN (as needed) for nausea, was present in the home but not listed on the Medicine List with a fill date of 12/30/24. HV # 2 stated he/she took this only when needed.

Meloxicam 15 mg tablet. One tablet daily/PRN for pain was present in the home but not listed on the Medicine List with a fill date of 2/9/24. HV # 2 said he/she had been on that forever.

Cetirizine 10 mg tablet. One tablet daily for allergies with a fill date of 3/15/25. He/she said the "doc" just started me on that a couple of weeks ago.

Aloe Burn Relief 0.5 % (percent) topical spray weekly/PRN for pain relief when changing mediport dressing was present in the home but not on the Medicine List.. HV # 2 said his/her wife/husband purchased that a few weeks ago and asked the nurses to use it when changing the mediport dressing.

An interview was conducted on 3/27/25 at 11:53 with EI # 1, Area Administrator of Operations, who confirmed the agency failed to reconcile medications per agency policy.

2. HV # 5 was admitted to the agency on 3/3/25 with diagnoses including Fracture of Unspecified Part of Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Hypothyroidism, Unspecified. 

A HV was conducted on 3/25/25 at 1:54 PM with EI # 6, Physical Therapist, to observe care provided. 

During the HV, the surveyor compared the medications found in home to the agency medicine list (ML). The patient verified the following medication discrepancies:

Aspirin 81 mg 1 tablet twice daily was found in the home. The caregiver verbalized taking the 81 mg twice daily dosage since 2/6/25 or 2/7/25. Aspirin 81 mg 1 tablet daily was on the agency ML. 

Meloxicam 7.5 mg 1 tablet daily was on the agency ML. The caregiver verbalized the patient had not taken Meloxicam since 2022.

An interview was conducted on 3/27/25 at 12:51 PM with EI # 2, Clinical Director, who confirmed the agency failed to ensure the medications were reconciled. 

3. HV # 7 was admitted to the agency on 2/6/25 with diagnoses including Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease and Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease. 

A HV was conducted on 3/26/25 at 9:12 AM with EI # 3, Occupational Therapist, to observe care provided. 

During the HV, EI # 3 and the surveyor compared the medications found in home to the agency ML. The patient verified the following medication discrepancies:

Aspirin 325 mg 1 tablet daily was found in the home. The patient verbalized taking the 325 mg dosage since August 24. Aspirin 81 mg 1 tablet daily was on the agency ML. 

Hydrochlorothiazide (HCTZ) 25 mg 1 tablet daily was found in the home. The patient verbalized taking the 25 mg dosage since December 24. HCTZ 12.5 mg three times day was on the agency ML.

Magnesium Citrate 200 mg 1 tablet daily was found in the home. The patient verbalized taking the magnesium citrate since January 25. There was no documentation of the magnesium citrate on the agency ML. 

Tramadol 50 mg 1 to 2 tablets every 8 hours as needed for pain was found in the home. The patient verbalized taking the Tramadol for the last three or four years. There was no documentation of the Tramadol on the agency ML. 

Valacyclovir 1 gm (gram) 1 tablet twice daily was found in the home. The patient verbalized taking the Valacyclovir since February 25. There was no documentation of the Valacyclovir on the agency ML. 

An interview was conducted on 3/27/25 at 12:59 PM with EI # 2 who confirmed the agency failed to ensure the medications were reconciled. 

1. HV # 3 was admitted on 2/6/25 with diagnoses including Urinary Tract Infection, Unspecified Atrial Fibrillation, and COVID-19. 

A review of the Home Health Certification and Plan of Care (HHC and POC) dated 2/6/25 revealed physician's orders for Skilled Nurse (SN) one visit per week for nine weeks. 

A HV was conducted on 3/25/25 at 12:15 PM to observe care provided by Employee Identifier (EI) # 4, Licensed Practical Nurse (LPN).

A review of the current medications was conducted with EI # 4 and HV # 3 and compared to the Medication List dated 3/25/25. The following is a list of the discrepancies:

a. Lasix 40 milligrams (mg) take one tablet two times a day was listed on the Medication List. 

HV # 3 stated he/she had been taking one tablet one time a day for one year. 

b. Coreg 3.125 mg, take one tablet daily was on the Medication List. 

HV # 3 stated the dosage was increased to 12 mg during her last physician office visit on 3/10/25. HV # 3 stated he/she had been taking three to four of the 3.125 mg tablets a day to increase the dosage. There was no new prescription of Coreg in the home. 

c. Jardiance 10 mg, take one daily, filled 3/10/25, was in the home with the current medications. HV # 3 stated the new prescription was added during her physician office visit on 3/10/25. 

An interview was conducted on 3/27/25 at 12:25 PM with EI # 9, Registered Nurse (RN), who confirmed the agency failed to ensure the medications were reconciled per agency policy.