Every finding on record at Adoration Home Health Nashville South

An Emergency Preparedness recertification and re-licensure survey was conducted on 3/16/2026-3/18/2026. The facility meets all of the requirements for Emergency Preparedness. There were no deficiencies identified.

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 policy review, medical record review, observation and interview, the agency failed to update the medication profile for 2 of 5 (Patient #1 and #5) sampled patients observed during home visits. The findings included: 1. Review of the agency’s policy “Home Health Clinical Practice Expectations,” revised 10/4/2024, revealed, “…A comprehensive review of medications requires seeing the medications…Medication reconciliation and medication teaching will be completed, and documented by every clinician, on every visit…” Review of the agency’s policy “MEDICATION ADMINISTRATION & [AND] MANAGEMENT,” revised 2/13/2026, revealed, “…The agency will reconcile patient’s medications at time of admission and on an ongoing basis in order to identify any potential adverse effects, contraindications and drug reactions, including ineffective drug therapy, significant side effects significant drug interactions, duplicate drug therapy and non-compliance with drug therapy…” 2. Medical record review for Patient #1 revealed a start of care date of 1/27/2026 with diagnoses including Heart Failure, Diabetes, and Rheumatoid Arthritis. Review of the “Home Health Certification and Plan of Care” for the certification period from 1/27/2026 to 3/27/2026, revealed the following medication orders: Ascorbic Acid (supplement) 500 milligrams (mg) 1 tablet oral daily over the counter (OTC) Calcium (supplement) 500 mg + D (supplement) 10 micrograms (mcg) 1 tablet oral daily (OTC) Ferro-time (supplement) 325 mg (Iron 65 mg) 5 tablets oral daily (OTC) Magnesium (supplement) 400 mg 1 tablet oral daily (OTC) Pantoprazole (used to treat heartburn and reduce stomach acid) 40 mg tablet delayed release 1 tablet oral daily Observations in Patient #1's home on 3/17/2026 at 12:15 PM, revealed the following medications in the home: Ascorbic Acid 1000 mg 1 tablet oral daily (OTC) Calcium 600 mg + D3 20 mcg 1 tablet oral daily (OTC) Magnesium 250 mg 1 tablet oral daily (OTC) Iron 65 mg 1 tablet oral daily (OTC) Fosinopril (used to treat high blood pressure) 40 mg 1 tablet oral daily Gemtesa (used to treat overactive bladder) 75 mg 1 tablet oral daily Leflunomide (used to treat arthritis) 20 mg 1 tablet oral daily Lidocaine (used to treat pain) 5% (percent) topical patch daily Meloxicam (used to treat pain) 15 mg 1 tablet oral daily Methocarbamol (used to treat muscle spasms) 750 mg 1 tablet oral 4 times daily as needed Miralax (used to treat constipation) 17 gram/dose oral powder oral daily as needed Multivitamin (supplement) 50 Plus 1 tablet oral daily Naloxone (used to treat overdose of opioid) 4 mg Nasal Spray as needed Potassium Chloride (used to treat essential mineral and electrolyte balance) 20 mEq (milliequivalent) extended release 1 tablet oral daily Omeprazole (used to treat heartburn and reduce stomach acid) 20 mg delayed release 1 capsule oral two times daily Ozempic (used to treat diabetes) 1 mg/subcutaneous pen injector one time a week on Friday Turmeric Root Extract (supplement) 1000 mg 2 tablets oral daily (OTC) Tylenol (used to treat pain) 650 mg extended-release tablet 2 tablets oral every 8 hours as needed Voltaren (used to treat pain) Arthritis Pain 1% topical gel 1 inch to each knee daily as needed (OTC) Vyzultia (used to treat glaucoma) 0.024% eye drops 1 drop to both eyes twice daily During an interview on 3/17/2026 at 12:15 PM, Patient #1 stated she was taking Ascorbic Acid, Calcium, Magnesium, Iron, Fosinopril, Gemtesa, Leflunomide, Lidocaine patch, Meloxicam, Methocarbamol, Miralax, Multivitamin, Naloxone Nasal Spray, Potassium, Omeprazole, Ozempic, Tylenol, Turmeric Root Extract, Voltaren, and Vyzultia. Pt. #1 stated she had been taking the medication “forever”, but she was not taking Pantoprazole. During an interview on 3/17/2026 at 12:30 PM, Registered Nurse (RN) #1 stated the facility medication list did not have all the medications listed, and she would have to notify the physician and update the list. 3. Medical record review for Patient #5 revealed a start of care date of 2/26/2026 with diagnoses including Neoplasm of Sigmoid Colon, Ileostomy, Seizures, and Hypertension. Review of the “Home Health Certification and Plan of Care” for the certification period from 2/26/2026 to 4/26/2026, revealed the following medication orders: Gabapentin (used to treat pain) 300 mg capsule oral two times daily Levetiracetam (used to treat seizures) 500 mg tablet oral daily Observations in Patient #5's home on 3/17/2026 at 10:10 AM, revealed the following medications: Gabapentin 300 mg capsule oral three times daily Levetiracetam 500 mg tablet oral twice daily During an interview on 3/17/2026 at 10:11 AM, Patient #5 stated “Gabapentin has always been three times a day, and Levetiracetam has been twice a day since July 15, 2025.” During an interview on 3/17/2026 at 10:12 AM, Licensed Practical Nurse #1 stated the facility medication list was not showing the correct frequency. 4. During an interview on 3/18/2026 at 10:05 AM, the Area Vice President stated staff should list all the patient's medications and physically observe the patient's medication bottles in the home.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on policy review, medical record review, and interview, the agency failed to send a completed summary to the physician within 5 days after the Discharge or a Transfer Summary with 2 days of the transfer for 2 of 4 (Patient #10 and #11) patients reviewed. The findings included: 1. Review of the agency's “Transfer and Discharge” policy dated 9/9/2025, revealed, “…A completed discharge summary will be sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the agency within five (5) business days of the patient’s discharge…” 2. Review of the medical record revealed Patient #10 was admitted to the agency on 4/3/2025 with diagnoses of Encounter for Orthopedic Aftercare, Radiculopathy, Lumbar Region, and Scoliosis. The patient was discharged on 6/1/2025. During an interview on 3/18/2026 at 9:10 AM, the Area Vice President stated the Discharge Summary was faxed to the physician on 6/10/2025 and confirmed it was late. Review of the medical record revealed Patient #11 was admitted to the agency on 10/17/2025 with diagnoses of Localization-related (focal) Symptomatic Epilepsy, Lennox-Gastaut Syndrome, Anxiety, Depression, and Vascular Headache. The patient was discharged 12/4/2025. During an interview on 3/18/2026 at 9:11 AM, the Area Vice President stated the Discharge Summary was faxed to the physician on 12/16/2025 and confirmed it was late.

An Emergency Preparedness survey was conducted along with a recertification survey beginning 2/27/23. The facility was found to be in compliance with all regulations reviewed related to Emergency Preparedness.

A recertification survey was conducted beginning on 2/27/23. The facility was informed of survey findings during an exit interview on 2/28/23.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on policy review, record review and interview, the facility failed to ensure coordination of care related to changes in patients conditions for 1 of 5 (Patient # 5) current patients reviewed. The findings included: 1. Review of the facility's "COORDINATION OF CARE" policy (revised 10/19/22) revealed, "...All personnel involved in the patient's care are responsible for coordinating care effectively to support the objectives outlined in the patient's plan of care...in order to assure the development and implementation of a coordinated care plan, the Agency will communicate with all physicians/allowed practitioners who give orders that are directly related to home health plan of care...The Agency will integrate services provided by various disciplines by...Assuring that staff who provide care are communicating any patient concerns and patient progress toward the goals identified in the plan of care with others involved in the patient's care..." 2. Medical record review for Patient #5 revealed a Plan of Care (POC) date of 1/27/23 through 3/27/23 with diagnoses that included Stage 4 Pressure ulcer to sacral area and Diabetes Mellitus Type 2. Review of Patient #5's POC revealed Skilled Nurse (SN) was to change the foley catheter monthly and as needed for malfunction (due week of 2/20/23). Review of a 2/6/23 Client Coordination Note revealed Patient #5's daughter called the agency to report the patient was having catheter issues. Patient #5 was having leaking from the catheter and also experiencing bladder spasms. The patient's daughter stated they should be okay until Wednesday (two days later, the next SN visit), and for the SN to be prepared to change the catheter. Review of SN visit notes revealed Patient #5 was not seen until 2/10/23. Review of the 2/10/23 SN note revealed the patient and daughter were upset. They were told a nurse would visit on Wednesday but no one came. There was no documentation the agency coordinated care with nursing staff to address the catheter issues with Patient #5, after receiving notification from the patient's daughter on 2/6/23. Further SN note review for Patient #5 revealed the patient's foley catheter was changed on 2/10/23. Review of the 2/21/23 SN note revealed the foley catheter was changed again, with no documentation of any malfunction or problems. There was no documentation the SN coordinated care with the physician on 2/21/23 to verify the foley catheter should be changed. Patient #5 was not experiencing malfunction or problems with the catheter. Patient #5's foley catheter had been changed on 2/10/23. In an interview on 2/28/23 at 1:30 PM, the agency's Regional Vice President stated she agreed the SN should have contacted the physician before changing the catheter on 2/21/23.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on policy review, record review and interview, the facility failed to ensure clinical notes were appropriately signed and dated for 1 of 5 (Patient #4) current patients reviewed. The findings included: 1. Review of the facility's "CLINICAL RECORDS" policy (revised 10/20/22) revealed, "...All entries in the clinical record must be legible, clear, complete, and appropriately authenticated, dated, and timed...Documentation shall be written on the day the service is delivered..." 2. Medical record review for Patient #4 revealed a Plan of Care (POC) date of 1/25/23 through 3/25/23 with diagnoses that included Congenital Malformation Syndrome. The POC revealed a physician's order for Skilled Nurse services 48 hours a week. Review of Skilled Nurse notes beginning 2/1/23 through 2/24/23 revealed the following: -There was no patient/caregiver signature for 2/21/23. -A 2/22/23 Skilled Nurse note was signed by the clinician and the patient/caregiver on 2/23/23. In an interview on 2/28/23 at 2:00 PM, the facility's Regional Vice President verified there was no patient/caregiver signature for the 2/21/23 Skilled Nurse note and verified the 2/22/23 Skilled Nurse note was not signed until the next day.