Desert Home Health Services, Inc.

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the patients and/or their caregivers were provided written instructions outlining the visit schedules and patient medication schedule/instructions, for five of seven patients reviewed during the home visits (Patients 4, 5, 10, 11, and 12). These failures had the potential to result in miscommunication between agency staff and patients regarding anticipated visits, and the potential for medication errors. 3. On August 3, 2026, Patient 10’s record was reviewed. Patient 10 was admitted to the agency with the SOC date of July 24, 2026, with diagnoses including joint replacement surgery (a type of procedure where a surgeon removes damaged or diseased parts of a natural joint and replaces them with an artificial implant). On August 4, at 8:35 a.m., a home visit was conducted with the Physical Therapist (PT) 1. PT 1 conducted therapy sessions and evaluated Patient 10’s performance for her transition to outpatient physical therapy. On August 4, 2026, at 9:15 a.m., PT 1 checked on Patient 10’s medication bottles. PT 1 asked Patient 10 and her family member (FM) if there were changes in her medications. Patient 10 and her FM stated there were no changes in her medications. In a concurrent interview with Patient 10’s FM, he stated that they (referring to himself and Patient 10) follow instructions from the medication bottles and from the medication list provided by the hospital when she was discharged. The FM stated he did not receive a medication list from the agency. On August 4, 2026, at 9:22 a.m., Patient 10’s folder was reviewed. A blank Medication Profile Form (did not contain patient name, caregiver name/s, SOC, date of birth [DOB]. Certification period, height, weight and diagnosis) and a blank calendar (did not contain any information indicating patient name, the frequency of visit, the SOC, visits made and the anticipated visits by agency staff) were found in Patient 10’s folder. In a concurrent interview with PT 1, he stated the admitting agency staff (Registered Nurse [RN]/PT/Occupational Therapist [OT]) should perform the medication reconciliation (a process of comparing a patient’s medication orders to all of the medications that the patient is actually taking), document in the medication profile and provide a written copy to the patient and/or family member. He also stated the licensed professional (RN/Licensed Vocational Nurse [LVN]/PT/OT) should perform medication reconciliation with every patient visit and document any changes in the patient’s medication profile. PT 1 stated Patient 10 did not have a written copy of her medication profile in her folder. PT 1 was asked about the blank calendar sheet. He stated he would inform the patient before he leaves regarding the date of his next visit and would call to confirm and remind the patient about the date and time of the next visit. PT 1 stated he does not document his next visit on the patient’s calendar. 4. On August 3, 2026, Patient 11’s record was reviewed. Patient 10 was admitted to the agency with the SOC date of July 24, 2026, with diagnoses including joint replacement surgery. On August 6, 2026, at 9:03 a.m., a home visit was conducted with PT 2. PT 2 initiated the home visit by performing medication reconciliation. PT 2 was observed to use a printed copy of Patient 11’s list of medications. On August 6, 2026, at 9:41 a.m., after PT 2 completed her home visit, Patient 11’s folder was reviewed. A blank Medication Profile and a blank calendar were found in Patient 11’s folder. PTA 2 stated she would leave the printed copy of Patient 11’s medication profile that she used to reconcile the medications for Patient 11’s record at home. She stated she always brought a printed copy of the patient’s medication profile with her with every visit and used it to reconcile the patient’s medications. PT 2 stated the RN should have provided Patient 11 with a copy of the medication profile when Patient 11 was admitted to the agency. She also stated that she informed patients of her anticipated visit before she would leave and would call a day before her scheduled visit. She stated she did not document the visits she made and the anticipated or upcoming visits in the calendar sheet. On August 6, 2026, at 9:55 a.m., Patient 11 was interviewed. She stated she took her medications according to the medication list provided by the hospital on the day she was discharged. She stated she did not receive a copy of her medication list from the agency. She stated the agency staff would tell her when the next visit would be and called her the day before to confirm the visit. 6. On August 3, 2026, Patient 12’s record was reviewed. Patient 12 was admitted to the agency with the SOC date of July 30, 2026, with diagnoses including joint replacement surgery. On April 6, 2026, at 11:25 a.m., a home visit was conducted with the PT Assistant (PTA). The PTA initiated the home visit by performing medication reconciliation. The PTA had a printed copy of Patient 12’s medication profile. The PTA informed Patient 12 that he would leave the copy of his medication profile in his folder. On April 6, 2026, at 12:25 p.m., Patient 12’s folder was reviewed. A blank Medication Profile and a blank calendar sheet were found in Patient 12’s folder. On April 6, 2026, at 12:32p.m., Patient 12 was interviewed. He stated he followed the instructions attached to the medication bottle. He stated he did not check the contents of the folder that was provided by the agency. He also stated the agency staff would tell him when the next visit would be and called him the day before to confirm the visit. On April 6, 2026, at 12:40 p.m., the PTA was interviewed. He stated he would perform medication reconciliation with every patient visit. The PTA did not answer when asked why the Medication Profile was blank. The PTA was asked about the blank calendar. He stated he informed his patients of his next visit verbally and called the patient the day before the anticipated visit for confirmation. He stated he did not use the calendar sheet. On August 6, 2026 at 5:10 p.m., in a concurrent interview with the Administrator (ADM) and Director of Patient Care Services (DPCS), the DPCS stated she expected the medication profiles to be in the patients’ home health packet in the home. The DPCS further stated the patient calendars should be labeled, and should contain at least the first weeks’ schedule then updated as future visits are arranged with the patient and CG. The undated agency policy and procedure titled, “CARE COORDINATION,” indicated, “…To ensure the coordination of services for each patient and to minimize the potential for missed, conflicting, or duplicated services…” The undated agency policy and procedure titled, “PATIENT EDUCATION PROCESS,” indicated, “,,,To provide guidelines for the provision of health information and instruction to patients and family/caregivers…The patients and family/caregivers will receive education in verbal, visual and written format…” The undated agency policy and procedure titled, “MEDICATION PROFILE,” indicated, “…The admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use of each medication ordered…A drug regimen review will be performed at the time of admission…Each patient and/or family/caregiver will receive appropriate written material for specific medications he/she receiving…The material will contain information on actions of the medication, potential side effects, contraindications, and any special instructions when taking the specific medication…” Findings: 1. On August 3, 2026, Patient 4’s record was reviewed. Patient 4 was admitted to the agency with the Start of Care (SOC) date of July 15, 2026, with diagnoses which included status post L3-L4 (lumbar spine) decompression, spacer implantation and fusion (permanent surgery that joins two or more back bones together). On August 4, 2026, at 8:30 a.m., a home visit was conducted with Registered Nurse (RN) 2 for Patient 4. A review of Patient 4’s home health folder indicated there was no medication profile inside the folder. In addition, the calendar of visits did not contain Patient 4’s information indicating the month or year, patient name, frequency, SOC date or any anticipated visits by agency staff. In a subsequent interview, RN 2 stated he reviewed Patient 4’s medication with Patient 4 and his caregiver(CG) using the electronic medication list on his electronic device and a printed medication list was no longer left with the patient in the home. As for the calendar of visits form, it was no longer filled out and the succeeding visits were verbally confirmed with the patient. Further, prior to the home visit, the visit would be confirmed with the patient or CG via phone in the morning of the visit, if the visit was scheduled in the afternoon, or the day before, if the visit was to be conducted the following morning. 2. On August 4, 2026, Patient 5’s record was reviewed. Patient 5 was admitted to the agency with an SOC date of July 24, 2026, with diagnoses which included aftercare following hip joint replacement surgery and presence of right artificial hip joint. On August 5, 2026, at 11:30 a.m., a home visit was conducted with RN 1 for Patient 5. A review of Patient 5’s home health folder indicated there was no medication profile inside the folder. In addition, the calendar of visits did not contain Patient 5’s information indicating the month or year, patient name, frequency, SOC date or any anticipated visits by agency staff. In a subsequent interview, RN 1 stated he reviewed Patient 5’s medications with the patient using the electronic medication list on his electronic device, and a printed medication list was not left with the patient in the home. As for the calendar of visits form, it was no longer filled out and the succeeding visits were verbally confirmed with the patient, and on the day of the visit, the visits would be confirmed with the patient or CG 1-2 hours prior to the time of the home visit.”

“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 facility failed to follow the standards of practice for infection control to prevent cross-contamination when the Certified Home Health Aide (CHHA) did not utilize a clean protective barrier prior to putting her personal belongings on top of Patient 9’s bedroom dresser. This failure had the potential for transferring environmental pathogens from surfaces to personal items, creating a risk of disease transmission for vulnerable patients. Findings: On August 3, 2026, Patient 9’s record was reviewed. Patient 9 was admitted to the agency with the Start of Care (SOC) date of July 25, 2026, with diagnoses including anterior displaced fracture of sternal end of left clavicle (broken collarbone). On August 4, 2026, at 10:13 a.m., a home visit was conducted with the CHHA for Patient 9. The CHHA was observed to place her personal belongings directly on the surface of Patient 9’s bedroom dresser without a protective barrier. On August 4, 2026, at 11:21 a.m., during an interview with the CHHA, the CHHA was asked about the use of protective barrier when she placed her personal belongings directly on top of Patient 9’s bedroom dresser. She stated she never used any protective barrier since she started working at the agency. On August 5, 2026, at 10:30 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated all agency staff got in-serviced on infection control and the staff were instructed to always put a protective barrier before putting down any of their personal belongings or patient supplies used for patient care on any surface area. The DPCS stated the barrier should be used as part of infection control. On August 5, 2026, at 10:30 a.m., in a concurrent interview with the administrator (ADM), she stated protective barriers are always available in the office for pick-up and could be picked up during the week. A review of the undated agency policy and procedure titled, “CLEAN vs ASEPTIC TECHNIQUE,” indicated, “…Clean Technique refers to infection control strategies utilized to reduce the number of microorganisms or to reduce or prevent the transmission of microorganisms from one person to another…Clean technique includes the following strategies…Incorporate the use of barrier precautions…””

“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 agency failed to ensure the medications listed in the patient’s Plan of Care (POC), and the current medication profiles, were updated accurately, for two of 17 sampled patients (Patients 5 and 6). These failures had the potential for the patients to not receive the medications as ordered by the physicians, placing the patients at risks for potential adverse side effects and drug interactions, duplicate drug therapy, and noncompliance with drug therapy. Findings: 1. On August 4, 2026, Patient 5’s record was reviewed. Patient 5 was admitted to the agency with an Start of Care (SOC) date of July 24, 2026, with diagnoses which included included aftercare following hip joint replacement surgery and presence of right artificial hip joint. Patient 5 had a surgery date of July 22, 2026. On August 5, 2026, at 11:30 a.m., a home visit involving observation, interview, and record review was conducted with Registered Nurse (RN) 1 for Patient 5. RN 1 stated this visit was also a discharge home visit. During the medication reconciliation review by RN 1, RN 1 asked Patient 5 about medications he was currently taking. Patient 5 brought out a rectangular plastic container with the following medications that were not listed on Patient 5’s “Medication Profile (effective date July 24, 2026),” which RN 1 brought with him to the home visit: - Gabapentin (used to treat nerve pain) 300 mg (milligram- unit of measurement) one capsule by mouth at bedtime, start after surgery; - Glucosamine (used to ease joint pain and reduce swelling) 1500 mg two tablets per day (over the counter stock); - Hydrochlorothiazide (lower high blood pressure and to treat swelling caused by heart failure) 25 mg take one tablet by mouth per day; - Atorvastatin (used to lower cholesterol levels)10 mg take one tablet by mouth daily; and - Vitamin D3 25 mcg (microgram- unit of measurement) /1000 IU [international unit- unit of measurement]), one soft gel daily (over the counter stock). RN 1 asked Patient 5 about the listed medication Oxycodone Hydrochloride (narcotic pain medication) 5 mg by mouth as needed, and Patient 5 stated he has not been taking the medication. RN 1 asked Patient 5 about the listed medication Suzetrigine (Journavx- used to treat moderat to severe short term pain, including post-operative pain) 50 mg tabs by mouth twice per day, and Patient 5 stated he has never received the medication and has therefore not taken it at all. In a subsequent interview, RN 1 stated the medication profile should have been updated at the SOC to capture all the medications the patient was taking, and if there were any missed, should have been captured in the succeeding visits. In addition, Patient 5’s medication profile should have been updated to discontinue the medications the patient was no longer taking. 2. On August 4, 2026, Patient 6’s record was reviewed. Patient 6 was admitted to the agency with the SOC date of July 31, 2026, with diagnoses which included aftercare following hip joint replacement surgery and presence of right artificial hip joint. Patient 6 had a surgery date of July 28, 2026. On August 5, 2026, at 10 a.m., a home visit involving observation, interview and record review was conducted with the Licensed Vocational Nurse (LVN). During a medication reconciliation review by the LVN, the following were observed: - The medication Famotidine (reduces acid in the stomach) was written in the “Medication Profile” as “40 MG (milligram- unit of measurement) Tab(s)…Oral…20 mg…Twice a day…’ whereas the label on the medication bottle indicated, “…FAMOTIDINE 20 MG TABLET…TAKE 1 TABLET BY MOUTH 2 TIMES A DAY START AFTER SURGERY…;” - One medication bottle was labeled “DOXYCYCLINE HYCLATE (an antibiotic) 100 MG CAP [capsule]…TAKE 1 CAPSULE BY MOUTH 2 TIMES A DAY FOR 1 DAY START AFTER SURGERY…” The quantity dispensed by the pharmacy was 2 capsules, and there were still 2 capsules inside the medication bottle on the day of the home visit (seven days after Patient 6’s surgery). The LVN asked Patient 6 about the listed medication Polyethylene Glycol (Smooth LAX- laxative powder) 3350 17 GM Packets, and Patient 6 stated she had not been taking the medication since she had also not been taking any narcotic pain medication since the surgery. In a subsequent interview, the LVN stated the Famotidine should have been written down correctly in the “Medication Profile” as it was written in the medication bottle to indicate the correct stock dose of 20 mg. The LVN also stated since the antibiotic Doxycycline was dispensed pre-operatively and was only ordered for one day and expected to have been consumed by the patient usually on post-operative day 1 and before the SOC, they would not have included it in the patient’s “Medication Profile.” However, since the medication was not consumed by the patient, a clarification order should have been made with the physician regarding the medication. The LVN further stated, since the patient had not been taking the medication Polyethylene Glycol, it should have been discontinued and removed from the patient’s medication profile. On August 6, 2026, at 5:10 p.m., during a concurrent interview with the Administrator (ADM) and Director of Patient Care Services (DPCS), the ADM stated a comprehensive medication reconciliation was expected to be conducted by the admitting nurse, where the medication list from the discharging physician, the current medication orders at the agency and the actual medication bottles are inspected to make sure all the medications are captured and listed on the patients’ medication profiles. The DPCS stated she expected the medication profiles to be complete, accurate and updated within the first week of the patients’ admission to the agency, and during subsequent visits, the medication profiles should be updated to ensure accuracy and correctness. The DPCS stated, regarding Patient 6’s antibiotic Doycycline, a clarification order should have been made with the patient’s physician to determine if the patient should continue to take the medication or not, or if the order for the antibiotic medication should be changed or the medication discontinued. The DPCS further stated if the issue was identified earlier, this would have also been a good opportunity for the skilled nurses to provide patient teaching about taking medications according to the physician’s orders. A review of the facility’s undated policy and procedure titled, “MEDICATION PROFILE,” indicated, “…Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications…For accuracy and to completely reconcile medications across the continuum of care, the admitting organization will obtain and document a complete list of the patient’s current medications upon the patient’s entry to the organization…The admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use of each medication ordered…A drug regimen review will be performed at the time of admission…The review will identify drug/food interactions, potential adverse effects and drug reactions, ineffective drug therapy, duplicative therapy, and noncompliance with drug therapy omissions and unclear information. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that he patient and family/caregiver, as well as other clinicians understand the medication regimen…Each patient and/or family/caregiver will receive appropriate written material for specific medications he/she receiving…Any conclusion or findings of patient medication use, including herbal and over the counter medication of monitoring should be communicated to the pharmacist, physicians, and other clinicians, when appropriate…Deviations in taking medications as ordered will be documented in clinical notes and the physician…will be notified… ””