Every finding on record at The Meadowood Corporation

Based on the findings of an unannounced on-site Medicare recertification survey conducted April 30, 2024, through May 2, 2024, Meadowood Home Health Agency was found to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Based on the findings of an unannounced on-site Medicare recertification survey conducted April 30, 2024, through May 2, 2024, Meadowood Home Health Agency was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

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 the review of agency policies, clinical records (CR), and interviews with agency staff, the agency failed to ensure that the Home Health Certification and Plan of Care (POC) and the medication profile contained all medications prescribed in accordance with the personal care (PC) facility physician’s orders and medication profile for two (2) of nine (9) CR reviewed. (CR # 7 and 8) Findings included: Review of agency policy titled “Medications” on May 1, 2024, at approximately 2:15 P.M. stated, “Overview: The unique/individualized Comprehensive Assessment includes a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions… Drug Regime Review: The drug regimen review includes an evaluation of ALL prescribed and over-the-counter medications the patient is using at the time of the Comprehensive Assessment… Those drugs (including over-the-counter drugs) and Cares that are ordered by the referring physician and not documented on the current Plan of Care are documented in the clinician’s visit note and added to the Medication Profile…” Review of CR on April 30, 2024, from approximately 11:00 A.M. to 2:00 P.M., May 1, 2024, from approximately 9:00 A.M. to 12:00 P.M. and May 2, 2024, from approximately 10:00 A.M. to 10:45 A.M. revealed the following: CR #7, start of care April 4, 2024. Certification period reviewed: April 4, 2024, through June 2, 2024. Review of the medications ordered on the POC and documented on the agency medication profile contained an order for Lidoderm 5% Topical Film (pain medication), one (1) patch, on in A.M. off at HS (hour of sleep), topical (applied to skin). Review of the PC facility medication profile contained an order for Lidocaine External Patch 4% (pain medication), apply to lower back topically one time a day for pain. CR #8, start of care March 20, 2024. Certification period reviewed: March 20, 2024, through May 18, 2024. Review of the medications ordered on the POC and documented on the agency medication profile contained an order for Avenova External Solution 0.01% (anti-microbial), apply thin layer every 12 hours PRN (as needed) for eye irritation drops, gel or ointment for the eye. Review of the PC facility medication profile revealed that Avenova External Solution was not listed. An interview with the Agency Administrator on May 2, 2024, at approximately 12:00 P.M. confirmed the above findings.