Self-Help Homecare & Hospice

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to follow accepted standards of practice to prevent the spread of infection when expired medical supplies were found in the medical supply room. This failure had the potential to expose patients to infectious disease. Findings: During a concurrent observation and interview on 7/8/24 at 9:10 a.m., with the Office Manager (OM), the following expired medical supplies were observed in the Medical Supply Room: 5 Pleurex Drainage Kits, expiration date 3/30/24 14 Luer Lock Disposable Syringes, expiration date 2/20/24 6 McKesson 60 cc syringes, expiration date 4/11/24 2 boxes (50 wipes per box) of Smith & Nephew Skin Prep wipes, expiration date 6/1/24 1 Suture Removal Tray, expiration date 6/30/24 8 BD Vacutainer Tubes, expiration date 3/31/24 3 boxes (30 test strips per box) of One Touch Test Strips, expiration date 2/29/24 2 boxes (30 test strips per box) of One Touch Test Strips, expiration date 12/31/23 During a concurrent interview with the OM, OM acknowledged the medical supplies were expired and she stated expired medical supplies should have been discarded. During an interview on 7/11/24, at 12:25 p.m., with the director of patient care services (DPCS), DPCS stated, medical supply expiration dates should have been checked monthly and expired medical supplies should have been removed from the supply room and discarded. DPCS stated she did not know where to dispose the expired medical supplies.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to verbally inform the family member (FM) for one out of three home visit patients, (Patient 3) regarding the toll-free home health hotline telephone number of the California Department of Public Health (CDPH) and it’s purpose for filing complaints. This failure had the potential to delay the complaint process and compromise patient rights. Review of Patient 3’s clinical records indicated, Patient 3’s start of care (SOC) to the home health agency was on 6/7/24 with diagnoses including acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm) and essential primary hypertension (high blood pressure that is multi-factorial and does not have one distinct cause). During a home visit observation of Patient 3 on 7/10/24 at 2:15 p.m., with registered nurse case manager (RNCM), Patient 3 was sitting in the chair, alert but confused, clean calm, and comfortable. Patient 3 was with her family member (FM) during the visit. During an interview with Patient 3’s FM on 7/10/24 at 2:35 p.m., FM said that she did not know about the toll-free home health hotline telephone number of CDPH and she was not informed about it. During an interview with RNCM on 7/10/24 at 2:40 p.m., RNCM stated that she did not know also about the toll-free home health hotline telephone number of CDPH and she will verify from their HHA office about the toll-free home health hotline telephone number of CDPH. During an interview with the director of patient care services (DPCS), on 7/11/24 at 10:15 a.m., DPCS verified that RNCM should have known the CDPH toll-free home health hotline telephone number. DPCS also stated, the family member of Patient 3 should have been informed of the CDPH toll-free home health hotline telephone number as well. DPCS confirmed, she would remind the HHA staffs regarding the toll-free home health hotline telephone number of CDPH. Review of the HHA’s policy and procedure titled, “Bill of Rights,” revised, May 2024 indicated, “The patient will be informed verbally and in writing during the initial evaluation visit and in advance of furnishing care of their rights. The Patient Bill of Rights statement defines the right of the patient to voice grievances regarding treatment or care that is (or fails to be) furnished, or regarding the lack of respect for property by anyone who is furnishing services on behalf of the organization and must not be subjected to discrimination or reprisal for doing so. Receive in writing prior to the start of care, the telephone numbers for the State Home Health Hotline and the CHAP Hotline, including hours of operation, and the purpose of the hotlines to receive complaints or questions about the organization. Use the hotlines to lodge complaints concerning the implementation of Advance Directive requirements.””

“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 observation, interview, and record review, the home health agency (HHA) failed to ensure medications were safe and effective for one of three patients (Patient 5) when one expired medication was found during a medication reconciliation at a home visit. This failure had the potential to result in negative patient outcomes. Findings: Review of Patient 5’s profile for the certification period, 6/21/24 through 8/19/24, indicated a start of care date (SOC) date of 6/21/24, and diagnoses of congestive heart failure (CHF, a chronic condition in which the heart doesn’t pump blood as well as it should) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). Review of Patient 5’s plan of care (POC) indicated Patient 5 complained of chest pain and shortness of breath more frequently recently and she took Nitroglycerin (medication used to prevent chest pain) sublingually (applied under the tongue) 1-2 tablets to relieve the symptoms. During a concurrent medication reconciliation observation and interview at a home visit, on 7/9/24 at 12:30 p.m., with Patient 5’s family member (FM), Nitroglycerin 4 milligrams (mg, a dose unit of measurement) with an expiration date of 4/2022 was observed. FM acknowledged the medication was expired. During an interview on 7/10/24, at 10:55 a.m., with the DPCS, she stated clinicians are supposed to check expiration dates when they did medication reconciliations. Review of the agency’s revised policy and procedure titled “Identification of Medication for Administration,” revised May 2024 indicated, “to provide guidelines for the safe administration of medications and all medications would be checked for expiration dates.””

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure case conferences (exchange of information between the patient’s care team to enhance patient’s care coordination) were held at the start of care for two of seven patients (Patient 4 and 5). This failure had the potential to compromise patient’s care coordination. Review of Patient 4’s profile for the certification period, 6/13/24 through 8/11/24, indicated a start of care date (SOC) of 6/13/24, and diagnoses of malignant neoplasm (abnormal growth of tissue) of the left kidney. Review of Patient 4’s plan of care (POC) indicated disciplines ordered for skilled nursing (SN) one visit per week times one week, two visits per week times two weeks and one visit per week times six weeks. There was no documentation in Patient 4’s clinical record a case conference was held at start of care. During a concurrent interview and record review, on 7/10/24, at 11:05 a.m., with the director of patient care services (DPCS), DPCS stated case conferences are held beginning with the SOC visit. DPCS stated the RN Case Manager (RNCM) did not come in for the case conference because she had to pick up a lot of SOC visits that week because the other case manager was off. DPCS stated they are supposed to call me and give me an update on how the SOC visit went. DPCS stated it did not happen and I forgot to call her. Review of Patient 5’s profile for the certification period, 6/21/24 through 8/19/24, indicated a start of care date (SOC) date of 6/21/24, and diagnoses of congestive heart failure (CHF, a chronic condition in which the heart doesn’t pump blood as well as it should) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). Review of Patient 5’s plan of care (POC) indicated disciplines ordered for skilled nursing one visit per week times one week, two visits per week times two weeks and one visit per week times seven weeks; and home health aide (HHA) two visits per week times eight weeks. There was no documentation in Patient 5’s clinical record a case conference was held at start of care. During a concurrent interview and record review, on 7/10/24, at 11:05 a.m., with the director of patient care services (DPCS), DPCS stated case conferences are held beginning with the SOC visit. DPCS stated the RN Case Manager (RNCM) did not come in for the case conference because she had to pick up a lot of SOC visits that week because the other case manager was off. DPCS stated they are supposed to call me and give me an update on how the SOC visit went. DPCS stated it did not happen and I forgot to call her. Review of the undated Registered Nurse Case Manager “Job Description” indicated “reports start of care assessment findings to DPCS...within 24 hours of completing the comprehensive assessment of the patient...” and “participates in bi-weekly mandatory case conference meetings, where the professional clinical team discusses patient care...” Review of the agency’s policy and procedure titled, “Case Conference/Progress Summary,” revised May 2024, indicated “case conferences are held at the start of care...to review and discuss all... cases.””

“Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient’s updated comprehensive assessment, and contain information concerning the patient’s progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure the plan of care (POC) was updated following a resumption of care (ROC) for one of seven patients (Patient 1). This failure had the potential to compromise patient health. Review of Patient 1’s profile for the certification period, 7/29/23 through 8/23/23, indicated a start of care date (SOC) of 7/29/23, and diagnoses of acute post hemorrhagic anemia (a condition in which someone losses a large volume of blood). Review of Patient 1’s plan of care (POC) indicated disciplines ordered were for skilled nursing (SN) one visit per week times one week, two visits per week times four weeks and one visit per week times five weeks. Review of Patient 1’s physician orders, dated 8/23/23, indicated Patient 1 was brought back on home health service on 8/23/23 following an admission to an acute care hospital due to sepsis (a life-threatening complication of an infection) and an altered mental status (AMS, change in mental function). During a concurrent interview and record review, on 7/11/24, at 11:35 a.m., with the director of patient care services (DPCS), DPCS stated Patient 1 was transferred to an acute care hospital on 8/8/23 due to a change of circumstance. DPCS acknowledged there was a resumption of care (ROC) visit made on 8/23/23 and stated there was no new plan of care (POC) after the ROC visit. During a telephone interview on 7/11/24, at 11:52 a.m., with the RN Case Manager (RNCM), RNCM stated she turned in her paper work for the ROC to the office. RNCM stated she did not generate the POC. RNCM stated it was the DPCS who generates the POC. During a subsequent interview on 7/11/24, at 12:25 p.m., with the DPCS, DPCS acknowledged the RNCM completed the ROC visit and turned in her documentation to the office. DPCS stated, it was the responsibility of the DPCS or quality assurance (QA) to generate the new ROC POC and send it to the doctor for change orders. DPCS stated it did not happen and she did not know what happened. Review of the agency’s policy and procedure titled “Significant Change In Condition”, revised 12/6/2005, indicated the “RN will complete a new OASIS (Outcome and Assessment Information Set) comprehensive assessment and obtain the necessary physician change orders.””

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide services as indicated in the plan of care (POC) for three out of seven sampled patients (Patients 2, 6, and 7) when: 1. For Patient 2, there were two missed skilled nursing (SN) visits, the reason for the missed visits were not documented, and the physician was not notified of the missed visits and; 2. For Patients 6 and 7, there was one missed SN visit, the reason for the missed visits were not documented, and the physician was not notified of the missed visits. These failures had the potential to result in the HHA’s inability to ensure that needed services and high-quality healthcare were provided to the patients. Review of Patient 2’s clinical records indicated, Patient 2’s start of care (SOC) with the home health agency (HHA), was on 9/23/23 with diagnoses including urinary tract infection (an infection in any part of the urinary system that includes the kidneys, ureters, bladder and urethra), site not specified, unspecified dementia (memory loss), unspecified severity, without behavior (the way in which someone conducts oneself), psychosis (mental disorder characterized by a disconnection from reality), mood (temporary state of mind or feeling) and anxiety (feeling of fear) and hypertensive heart disease (includes problems with the heart that can develop for having high blood pressure and not treated for years) with heart failure (a chronic condition in which the heart does not pump blood as well as it should). Review of Patient 2’s plan of care (POC) for the certification period, 9/23/23 through 11/21/23, indicated, discipline ordered was skilled nursing (SN) only. SN visit frequency orders were once per week for one week, for 9/23/23; twice per week for two weeks, from 9/24/23 to 10/21/23; once per week for five weeks, from 10/22/23 to 11/19/23 and two as needed SN visits, from 9/21/23 to 11/19/23. Review of Patient 2’s schedule report for the certification period, 9/23/23 through 11/21/23, indicated there was a missed skilled nursing visit for the week of 10/1/23 to 10/7/23 and for the week of 10/8/23 to 10/14/23. During a concurrent record review of Patient 2’s clinical records and interview with the director of patient care services (DPCS), on 7/11/24 at 9:21 a.m., DPCS verified the missed skilled nursing visits of Patient 2 for the week of 10/1/23 to 10/7/23 and for the week of 10/8/23 to 10/14/23. DPCS further verified that there was no documentation of the reason why the visit was missed by SN and the doctor was not notified of the missed visits. Review of the clinical records of Patient 6 indicated, that the SOC of Patient 6 with the HHA, was on 5/31/24 with diagnoses including hemiplegia (paralysis affecting only one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, aphasia (a language disorder affecting a person’s ability to communicate) following cerebral infarction and essential primary hypertension (high blood pressure that is multi-factorial and doesn’t have one distinct cause). Review of the POC of Patient 6 for the certification period, 5/31/24 through 7/29/24, indicated, disciplines ordered were SN and speech therapist (ST). SN visit frequency orders were once per week for one week, from 5/31/24 to 6/1/24; twice per week for four weeks, from 6/2/24 to 6/29/24; once per week for four weeks, from 6/30/24 to 7/27/24 and two as needed SN visits, from 5/29/24 to 7/27/24. Review of the schedule report of Patient 6 for the certification period, 5/31/24 through 7/29/24, indicated there was a missed skilled nursing visit for the week of 6/23/24 to 6/29/24. During a concurrent record review of the clinical records of Patient 6 and interview with DPCS on 7/11/24 at 9:35 a.m., DPCS verified that there was a missed skilled nursing visit of Patient 6 for the week of 6/23/24 to 6/29/24. DPCS further verified that there was no documentation of the reason why the visit was missed by SN and the doctor was not notified of the missed visit. Review of Patient 7’s clinical records indicated, that the SOC of Patient 7 with the HHA, was on 4/26/24 with diagnoses including pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of right heel (back part of human foot below the ankle), unstageable (an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar which is either tan, brown or black in color, in the wound bed), unspecified severe dementia (advanced or later stages of memory loss), without behavior, psychosis, mood, anxiety and type 2 diabetes mellitus (adult-onset, high levels of sugar in the blood) with hyperglycemia (high blood sugar). Review of Patient 7’s POC for the certification period, 4/26/24 through 6/24/24, indicated, discipline ordered was for SN only. SN visit frequency orders were once per week for one week, from 4/26/24 to 4/27/24; three times per week for two weeks, from 4/28/24 to 5/11/24; twice per week for three weeks, from 5/12/24 to 6/1/24; once per week for three weeks, from 6/2/24 to 6/22/24; twice per week for three weeks, from 6/6/24 to 6/22/24 and two as needed SN visits, from 4/26/24 to 6/24/24. Review of Patient 7’s schedule report for the certification period, 4/26/24 through 6/24/24, indicated there was a missed skilled nursing visit from 6/6/24 to 6/22/24. During a concurrent record review of Patient 7’s clinical records and interview with DPCS on 7/11/24 at 10:02 a.m., DPCS verified that there was a missed skilled nursing visit of Patient 7, from 6/6/24 to 6/22/24. DPCS further verified that there was no documentation of the reason why the visit was missed by SN and the doctor was not notified of the missed visit. Review of the home health agency’s policy and procedure titled, “Missed Visits,” revised May 2024 indicated, “Missed visits will be communicated to the clinical supervisor and the patient’s physician (or allowed practitioner). A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled, the clinician will notify the physician (or allowed practitioner) of the missed visit if there is potential for clinical impact upon the patient. The physician (or allowed practitioner) will decide if the visit may be skipped or additional intervention is required by the organization.””

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure visit notes were completed in a timely manner for four of seven patients (Patients 1, 4, 5, and 6). These failures had the potential to negatively impact patient care. Review of the clinical records of Patient 6 indicated, that the start of care (SOC) of Patient 6 with the home health agency (HHA), was on 5/31/24 with diagnoses including hemiplegia (paralysis affecting only one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, aphasia (a language disorder affecting a person’s ability to communicate) following cerebral infarction and essential primary hypertension (high blood pressure that is multi-factorial and doesn’t have one distinct cause). Review of the plan of care (POC) of Patient 6 for the certification period, 5/31/24 through 7/29/24, indicated, disciplines ordered were skilled nursing (SN) and speech therapist (ST). SN visit frequency orders were once per week for one week, from 5/31/24 to 6/1/24; twice per week for four weeks, from 6/2/24 to 6/29/24; once per week for four weeks, from 6/30/24 to 7/27/24 and two as needed SN visits, from 5/29/24 to 7/27/24. During a concurrent record review of the clinical records of Patient 6 and interview with the director of patient care services (DPCS), on 7/11/24 at 9:25 a.m., DPCS verified that skilled nursing (SN) visits were made on 6/17/24, 6/24/24 and 7/1/24 and the SN visit notes, were still not completed and submitted as of 7/11/24, more than 72 hours from the visit. DPCS further verified that the SN visit notes should have been completed and should have been done in a timely manner. Review of the home health agency’s policy and procedure titled, “Timely Submission of Patient Documentation,” revised 6/2024, indicated, “The Agency will ensure the timely and proper submission of patient documentation. Itineraries, with all visit reports attached, must be submitted the next scheduled work day, not exceeding three (3) calendar days..........” Review of Patient 1’s profile for the certification period, 7/29/23 through 8/23/23, indicated a start of care date (SOC) of 7/29/23, and diagnoses of acute post hemorrhagic anemia (a condition in which someone losses a large volume of blood). Review of Patient 1’s plan of care (POC) indicated disciplines ordered were for skilled nursing (SN) one visit per week times one week, two visits per week times four weeks and one visit per week times five weeks. Review of Patient 1’s physician orders, dated 8/23/23, indicated Patient 1 was brought back on home health service on 8/23/23 following an admission to an acute care hospital due to sepsis (a life-threatening complication of an infection) and an altered mental status (AMS, change in mental function). During a concurrent interview and record review, on 7/11/24, at 10:50 a.m., with the director of patient care services (DPCS), DPCS stated, Patient 1 was discharged to hospice on 9/5/23 and the discharge summary was submitted on 9/29/23. DPCS stated it should have been submitted on 9/7/23 or 9/8/23. Review of the agency’s policy and procedure titled, “Timely Submission of Patient Documentation,” revised 6/2024, indicated “upon discharge from services, the patient discharge summary must be submitted within two (2) days.” Review of Patient 4’s profile for the certification period, 6/13/24 through 8/11/24, indicated a start of care date (SOC) of 6/13/24, and diagnoses of malignant neoplasm (abnormal growth of tissue) of the left kidney. Review of Patient 4’s plan of care (POC) indicated disciplines ordered were for skilled nursing (SN) one visit per week times one week, two visits per week times two weeks and one visit per week times six weeks. Review of Patient 4’s calendar of visits indicated skilled nursing visits were made by the RN Case Manager (RNCM) on 6/18/24, 6/19/24, 6/25/24, and 6/27/24. Further review indicated visit notes were pending. During a concurrent interview and record review on 7/10/24, at 10:13 a.m., with the director of patient care services (DPCS), DPCS acknowledged the visit notes were pending. DPCS stated they are supposed to turn in their documentation within 48 hours. During an interview on 7/10/24, at 10:55 a.m., with the Administrator (ADM), ADM stated, we are aware that late documentation is an issue. ADM stated we do not have a Quality Assurance (QA) nurse right now. ADM stated we are training someone now to do chart reviews and to check that documentation is turned in within 48 hours. During a telephone interview on 7/11/23, at 11:52 a.m., with the RN Case Manager (RNCM), RNCM stated documentation should be turned in within 48 hours. Review of the undated Registered Nurse Case Manager “Job Description” indicated completes patient-related documentation; such as routine visit notes...within 24 hours of the shift worked. Review of the agency’s policy and procedure titled, “Timely Submission of Patient Documentation,” revised 6/2024, indicated “the agency will ensure the timely and proper submission of patient documentation...” Review of Patient 5’s profile for the certification period, 6/21/24 through 8/19/24, indicated a start of care date (SOC) date of 6/21/24, and diagnoses of congestive heart failure (CHF, a chronic condition in which the heart doesn’t pump blood as well as it should) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). Review of Patient 5’s plan of care (POC) indicated disciplines ordered were for skilled nursing one visit per week times one week, two visits per week times two weeks and one visit per week times seven weeks and home health aide (HHA) two visits per week times eight weeks. Review of Patient 5’s calendar of visits indicated a skilled nursing visit note on 7/3/24 was pending. Further review indicated HHA visit notes on 7/2/24, 7/6/24, and 7/9/24 were pending. During a concurrent interview and record review on 7/10/24, at 10:55 a.m., with the director of patient care services (DPCS), DPCS acknowledged the SN visit note on 7/3/24 was pending and stated RN Case Manager (RNCM) made a visit on 7/3/24 but did not document the visit. DPCS acknowledged the HHA visit notes were pending and stated they are supposed to turn in their documentation within 48 hours. During an interview on 7/10/24, at 10:55 a.m., with the Administrator (ADM), ADM stated, we are aware that late documentation is an issue. ADM stated we do not have a Quality Assurance (QA) nurse right now. ADM stated we are training someone now to do chart reviews and to check that documentation is turned in within 48 hours. During a telephone interview on 7/11/23, at 11:52 a.m., with the RN Case Manager (RNCM), RNCM stated documentation should be turned in within 48 hours. Review of the undated Registered Nurse Case Manager “Job Description” indicated completes patient-related documentation; such as routine visit notes...within 24 hours of the shift worked. Review of the agency’s policy and procedure titled, “Timely Submission of Patient Documentation,” revised 6/2024, indicated “the agency will ensure the timely and proper submission of patient documentation...””

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to notify the physician about the discontinued medication for one out of seven sampled patients (Patient 3). The discontinued medication of Patient 3 was not communicated to the physician by the registered nurse case manager (RNCM), not documented in the clinical notes, and it was included in Patient 3’s medication profile. These failures had the potential to compromise the quality of care and evaluation of treatment of the patient. Review of Patient 3’s clinical records indicated, Patient 3’s start of care (SOC) to the home health agency was on 6/7/24 with diagnoses including acute respiratory failure (an inability to maintain adequate oxygenation for tissues or adequate removal of carbon dioxide from tissues) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), unspecified atrial fibrillation (an irregular and often very rapid heart rhythm), and essential primary hypertension (high blood pressure that is multi-factorial and does not have one distinct cause). During a home visit observation of Patient 3 on 7/10/24 at 2:15 p.m., with registered nurse case manager (RNCM), Patient 3 was sitting in the chair, alert but confused, clean calm, and comfortable. Patient 3 was with her family member (FM) during the visit. During the medication reconciliation (the process of comparing a patient’s medication orders to all of the medications that the patient had been taking) of Patient 3’s medications with registered nurse case manager (RNCM) on 7/10/24 at 2:42 p.m., Patient 3 did not have the Umeclidinium/Vilanterol (Anoro Ellipta, commonly used as a controller inhaler for chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), which includes chronic bronchitis (an inflammation of the airways in the lungs) and emphysema (lung condition that causes shortness of breath) of the lungs), 62.5-25 microgram (MCG, unit of mass or weight equal to one millionth of a gram)/actuation (ACT, release of a single dose of the formulation, which contains the medication either dissolved or suspended in the propellant), in her home medications. During an interview with FM on 7/10/24 at 2:45 p.m., FM verified that Patient 3 did not use the Anoro Ellipta, 62.5-25 MCG/ACT for a while. During an interview with RNCM on 7/10/24 at 2:50 p.m., RNCM verified that the Anoro Ellipta, 62.5-25 MCG/ACT, should have been discontinued, and that’s why, it was not in Patient 3’s home medications. During an interview with the director of patient care services (DPCS), on 7/11/24 at 10:25 a.m., DPCS verified that the Anoro Ellipta, 62.5-25 MCG/actuation ACT of Patient 3, should have been discontinued but the physician was not informed by the RNCM about the medication. DPCS also stated, there was no discontinued order for Anoro Ellipta and the physician did not sign the discontinued order. There was no documentation in the clinical notes of the RNCM about the discontinued medication. Review of the home health agency’s policy and procedure titled, “Medication Profile,” revised May 2024, indicated, “Patient receiving medications administered by the organization, will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new, and/or discontinued medications. Deviations from taking medications as ordered will be documented in clinical notes, and the physician (or allowed practitioner) will be notified.”