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 017050 (X3) Date Survey Completed 12/17/2025
Name of Provider or Supplier Central North Alabama Health Services, Inc. Street Address, City, State 1310 Pulaski Pike, Unit A, Huntsville, 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 agency policy and procedure, observation, and interview, it was determined the agency failed to ensure medication reconciliation was performed on 2 of 3 Home Visits (HV), including HV # 1 and HV # 3.  This had the potential to affect all patients served by the agency.

 

Findings include:

 

Policy: Medication Monitoring

Policy Number: HHS.065

Policy Date: None

 

Purpose:

 

To define the ongoing medication monitoring process for the home care patient/client.

 

Policy:

 

.... The results of patient/client medication monitoring will be used to improve the patient's/clients medication regime.  The ongoing monitoring will occur in accordance with the established goal of therapy and be used to:

 

a. Evaluate the continued use of a medication in this current regimen.

 

b. Evaluate the patient/client adherence to the prescribed medication regimen.

 

Standard Operating Procedures:

 

5. Medication reconciliation will be conducted by the nurse during all home visits, and a reconciled list of medications will be retained in the patient/client home. 


2. HV # 3 was admitted to the agency on 11/21/2025 with a diagnosis of Chronic Systolic (Congestive) Heart Failure.

 

A home visit was conducted on 12/17/25 at 10:00 AM with EI # 3, Home Health Aide. 

 

A comparison was made between medications observed in the home and the MP.  The following discrepancy was found: 

 

1. Lidocaine Patch 5% 700 mg (50 mg per gram), daily as needed was observed in the home and not listed on the MP. HV # 3 confirmed the patches were used as needed.   

 

An interview was conducted on 12/17/25 with EI # 1, who confirmed the agency failed to ensure medication reconciliation was performed.

 

1. HV # 1 was admitted to the agency on 7/24/23 with a diagnosis of Urinary Tract Infection. 

 

A home visit was conducted on 12/16/25 at 12:30 PM with Employee Identifier (EI) # 2, Physical Therapist. 

 

A comparison was made between medications observed in the home and the medication profile (MP).  The following discrepancies were found:

 

1. Hydrocodone/Acetaminophen, 1 tablet as needed with fill date 12/4/25 was observed in the home and not listed on the MP.  

 

2. Cyclobenzaprine 10 milligram (mg) tablet, three times a day as needed with fill date 11/6/25 was observed in the home and not listed on the MP.

 

3. Escitalopram 10 mg tablet, 1 tablet daily with fill date 10/20/25 was observed in the home and not listed on the MP.

 

4. Isosorbide Mononitrate 30 mg Extended Release (ER) tablet, 1 tablet daily with fill date 10/20/25 was observed in the home and not listed on the MP. 

 

5.  Metoprolol ER Succinate 25 mg, 1 tablet daily with fill date 10/20/25 was observed in the home and not listed on the MP.

 

6. Vitamin D3, 25 microgram (mcg) and Vitamin B12, 1000 mcg was observed in the home and not listed on the MP. HV # 1’s caregiver stated the patient started taking both vitamins about two months ago.

 

7. Wellbutrin XL 300 mg tablet ER, 1 tablet daily was observed on the MP and not observed in the home. HV # 1’s caregiver stated the Wellbutrin XL was discontinued last month. 

 

8. Zofran 4 mg tablet, 1 tablet daily as needed was listed on the MP and not observed in the home. HV # 1’s caregiver stated it was discontinued a few months ago.

 

 An interview was conducted on 12/17/25 with EI # 1, Administrator, who confirmed the agency failed to ensure medication reconciliation was performed.