DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
741536 A. BUILDING __________
B. WING ______________ 		12/17/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
CALIDAD HOME HEALTH 1600 E EXPRESSWAY 83, LA FERIA, TX, 78559
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
L0530      
36596 Based on record review and interview the agency Skilled Nurse failed to include a MAR on the initial Comprehensive assessment for 1 of 1 discharged patient (Patient #1) whose record was reviewed. This failure places the agency's active patients at risk for adverse drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The Findings Included: Review of the electronic clinical record for Patient #1 revealed a start of care date of 12/08/21, with a diagnosis of Malignant Neoplasm of Connective and Soft Tissue. Continued review of the electronic clinical record for Patient #1 revealed the initial Comprehensive assessment which was dated 12/08/21 and signed by RN A. Continued review of the initial comprehensive assessment revealed that the section titled "Medication Administration Record" was left blank. Still further review of the electronic clinical record for Patient #1 revealed a Discharge Summary which was dated 12/14/21 and was signed by RN A. Continued review of the Discharge Summary revealed a "Current Medication Profile at Discharge" it listed 13 medications, with start date, medication, rout, form, strength, dose and frequency. An Interview was conducted on 12/16/21 at 10:46 a.m. with RN A review of the electronic clinical record was done, after review RN A, agreed with the following: -The Medication Administration Record was not completed during the initial comprehensive assessment. -A review of all the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments were not documented on the initial Comprehensive Assessment. -A review of the Effectiveness of drug therapy, Drug side effects, Actual or potential drug interactions, Duplicate drug therapy and Drug therapy currently associated with laboratory monitoring were not documented on the initial Comprehensive Assessment. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Initial Patient Assessment/Patient Admission", it was numbered PE.3 and had a revision date of 02/16/20. It read in part: "A Registered Nurse will complete the Initial Health Assessment." Continued review of the Initial Patient Assessment/Patient Admission policy read in part: "H. The initial Comprehensive Health Assessment, with input from appropriate IDT members and the attending physician will include the following: "Medication history, Medications currently prescribed, Medication compliance history, Side effects, drug allergies, sensitivities and past adverse drug reactions actual or potential interactions, Effectiveness of drug therapy, Food and environmental allergies, Duplicate drug therapy and Drug therapy currently associated with laboratory monitoring." Continued review of the Initial Patient Assessment/Patient Admission policy read in part:" The initial assessment data/information will be gathered and documented on the following forms: Medication Record Form." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Medication List and Monitoring", it was numbered TX.20 and had a revision date of 10/01/15. It read in part: "A medication profile will be maintained on all patients. Medication monitoring will include appropriated date/information to develop an accurate medication history and current complete medication profile." Continued review of the Medication List and Monitoring policy read in part: "Agency will maintain a current, accurate list of all prescription and over-the counter medications taken by the patient."