Inland Home Health Providers Inc.

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on interview, and record review, the agency failed to demonstrate staff knowledge of emergency procedures for two of seven sampled patients (Patients 1 and 3) when a Certified Home Health Aide (CHHA) and a Licensed Vocational Nurse (LVN) could not explain the backup plan in the event of a communications failure. This failure had the potential to cause delays in emergency response and place patients at risk during a communications failure. 1. A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 6, 2026, with a certification period of February 6, 2026, to April 6, 2026. Patient 1 had diagnoses that included hypertensive heart disease (heart problems caused by long‑term high blood pressure). During Patient 1’s home visit and interview on April 7, 2026, from 12 PM to 1 PM with CHHA 1, CHHA 1 stated the agency had provided her with an in-service on the Emergency Preparedness Program (EPP), but she was concerned because she did not know what to do if the landline phones, cellular phones, and Internet went down during an emergency or disaster. CHHA 1 stated she would not know how to get in contact with the agency to receive instructions on how to assist patients during the emergency or disaster. 2. A review of Patient 3’s face sheet, undated, indicated a start of care date of February 26, 2020, with a recertification period of March 26, 2026, to May 24, 2026. Patient 3 had diagnoses that included hypertensive heart disease with heart failure (structural and functional heart damage caused by long-term high blood pressure, resulting in the heart’s inability to pump efficiently). During Patient 3’s home visit and interview on April 8, 2026, from 10:30 AM to 10:45 AM with LVN 1, LVN 1 stated the agency had provided her with an in-service on the EPP, but she did not know what to do if the landline phones, cellular phones, and Internet went down during an emergency or disaster. LVN 1 stated she would not know how to get in contact with the agency to receive instructions on how to assist patients during the emergency or disaster. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on April 9, 2026, at 2:58 PM, the Admin/DPCS stated she was responsible for the EPP. The Admin/DPCS confirmed CHHA 1 and LVN 1 had received the in-service on the agency’s EPP and should have known that, in the event of a communications failure, they were to proceed to the agency’s office location if it was safe to do so; if not, they were to proceed to the alternate site, which was the Admin/DPCS’s home location. A review of the agency’s policy and procedure (P&P) titled, “Emergency Preparedness Policy,” dated November 2022, indicated, “C. Communication Plan. The agency must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every two years. The Communication Plan must include all of the following: … 3. Primary and alternate means of communicating with the agency staff …” A review of the agency’s P&P titled, “Emergency Preparedness Plan,” dated November 2022, indicated, “The Administrator or designee will declare the emergency and activate the Disaster Tree Phone Communication Plan. The Administrator/Designee will begin the process of notifying the employees on the disaster recall teams. Current employees telephone lists are located in the Emergency Preparedness Binder. Employees will be directed to report to the office as soon as possible. In an emergency, it is possible that telephone service will not be available. When staff members are aware of a disaster and do not receive a call within one-half hour, they should attempt to call the office. If regular telephone service is not available, employees should attempt to call by cell phone. If there are no means of communication, employees should proceed to the office after ensuring the safety of their homes and families. Agency personnel will bring personal cell phones to the agency for use during the emergency. If office is not within a safe area the emergency alternative meeting place will be utilized. Once the Emergency Plan has been activated and personnel have gathered at the office or alternate location, the Administrator or designee will assign personnel to the Medical Team if necessary. …””

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure a Registered Nurse (RN) provided a Certified Home Health Aide (CHHA) with written patient care instructions for one of seven sampled patients (Patient 1) when the Home Health Aide Care Plan did not include required blood pressure reporting parameters (indicating what blood pressure readings to report to the physician). The care plan did not specify the systolic (the top number in a blood pressure reading which shows how much pressure is in the arteries when the heart squeezes to pump blood out to the body) or diastolic (the bottom number in a blood pressure reading which shows how much pressure is in the arteries when the heart relaxes between beats) thresholds that would require the CHHA to notify the Skilled Nurse (SN) or physician. As a result, the CHHA lacked clear criteria to identify, report, or escalate abnormal blood pressure readings. This failure had the potential to cause a delay in recognizing and reporting clinically significant changes in the patient’s blood pressure, which could result in unmet care needs, delayed clinical intervention, and decline in Patient 1 health status. Findings: A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 6, 2026, with a certification period of February 6, 2026, to April 6, 2026. Patient 1 had diagnoses that included hypertensive heart disease (heart problems caused by long‑term high blood pressure). During a home visit and interview on April 7, 2026, from 12 PM to 1 PM with CHHA 1 and Patient 1’s daughter in law, CHHA 1 took Patient 1’s blood pressure and stated the reading was 95 systolic and 52 diastolic, which was a little low for Patient 1. CHHA 1 stated she would retake the blood pressure after giving Patient 1 her shower. Patient 1’s daughter in law stated the physician had discontinued a blood pressure medication on April 3, 2026, because Patient 1’s blood pressure had been chronically lower and they were monitoring it. CHHA 1 reviewed her home health aide care plan and confirmed there were no reporting parameters for the blood pressure reading. CHHA 1 completed her cares for Patient 1 and left the house without retaking or reporting the blood pressure reading to the SN or physician. A review of Patient 1’s “Home Health Aide Care Plan,” dated February 6, 2026, to April 6, 2026, and April 7, 2026, to June 5, 2026, was conducted. There was no documented evidence to show reporting parameters for blood pressure readings. A review of Patient 1’s nursing care plan dated February 6, 2026, to April 6, 2026, and April 7, 2026, to June 5, 2026, indicated “SN to observe for progression/decline in functional status and report any significant findings to PCP [Primary Care Physician]. SN to report to MD [Medical Doctor] if the following condition occurs: … BP [blood pressure] above 170 [systolic]/90 [diastolic] or below 90/60 …” During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and the Director of Patient Care Services Designee (DPCSD) on April 8, 2026, at 2 PM, the Admin/DPCS confirmed there were no blood pressure reporting parameters on Patient 1’s Home Health Aide Care Plan and stated there should be. The Admin/DPCS stated that, based on the nursing care plan, CHHA 1 should have reported Patient 1’s blood pressure reading of 95/52. A review of the agency’s policy and procedure (P&P) titled, “Certified Home Health Aide Services,” dated December 2016, indicated, “PURPOSE: To ensure that Certified Home Health Aide (CHHA) are competent and are closely supervised with the service they provide to the patients. To select home health aide with sympathetic attitude toward the care of the sick, has the ability to read, write and carry out directions, and maturity and ability to deal effectively with the demands of the job. POLICY: Personal care services provided by the agency personnel are delivered according to written instructions that reflect the assessment of the patient’s needs and/or clinical status, and the physician’s orders and plan of care. CHHA services may include but not be limited to the following duties: … taking vital signs, … Assignment. The CHHA is assigned to a specific patient by the registered nurse. Written patient care instructions for the CHHA must be prepared by the registered nurse or other appropriate professional who is responsible for the supervision of the CHHA. … PROCEDURE: The Registered Nurse or licensed therapist initiates the Home Health Aide Care Plan during the admission visit in cooperation with the patient and/or significant other. A copy of the completed Home Health Aide Care Plan is available in the medical record of the respective patient assigned to the CHHA. The Home Health Aide Care Plan is reviewed and updated by the RN or licensed therapist according to the patient’s needs and/or clinical status. …””

“Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency’s overall management and operation, the provision of all home health services, fiscal operations, review of the agency’s budget and its operational plans, and its quality assessment and performance improvement program. This Standard is not met as evidenced by: Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from March 24, 2023 (the last standard recertification survey), to April 6, 2026, in a universe of 49 patients (Patients 1 to 49) when a current California Department of Public Health (CDPH) Laboratory Registration was not maintained. This failure caused the agency to perform waived laboratory testing without CDPH oversight for the three year period reviewed. Finding: During an agency tour on April 6, 2026, from 10:40 AM to 11:08 AM, the agency’s postings were reviewed. There was no posting of a California Department of Public Health (CDPH) Laboratory Registration, for the agency. In a continued tour of the agency the agency’s medical supplies were reviewed. One medical supply drawer contained 17 specimen collection cups (sterile, single-use, medical-grade plastic container used to safely collect, transport, and store biological samples—primarily urine, but also stool or sputum), six specimen swab kits (sterile medical tools used to collect biological samples from the body--nose, throat, mouth, vagina, rectum--for laboratory testing) and one blood collection set (used to draw blood for laboratory testing). During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) on April 6, 2026, at 11:08 AM, the Admin/DPCS acknowledged that one medical supply drawer contained 17 specimen collection cups, six specimen swab kits, and one blood collection set. The Admin/DPCS stated she was a member of the agency’s Governing Body (GB) and that it was her responsibility to ensure the agency’s CDPH Laboratory Registration was kept current and active. The Admin/DPCS stated she had been unaware of the requirement to obtain a CDPH Laboratory Registration. The Admin/DPCS stated a CDPH Laboratory Registration had not been obtained or maintained by the agency for the three‑year period reviewed. A review of the agency’s policy and procedure (P&P) titled, “Governing Board,” dated January 2011, indicated “PURPOSE: To delineate the authority and responsibilities of the Governing Board. POLICY: The Governing Board is the governing body for [Name of the Agency] and shall assume full legal authority and responsibility for the operation of the agency. The governing body shall: … 2. Assume responsibility for the management and fiscal affairs of the agency. …””

“Property and person treated with respect CFR(s): 484.50(c)(1) Have his or her property and person treated with respect; This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure personal respect and privacy for one of seven sampled patients (Patient 3) when a Skilled Nurse (SN) performed a body assessment and an assessment and care for a urinary appliance (a device used to collect or drain urine from the body when a person cannot urinate normally) for Patient 3, a male patient, in a front room common area of a Board and Care Facility (B&C — a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming), in the presence of another female patient who attentively watched the procedures. This failure had the potential to cause embarrassment, loss of dignity, and emotional distress for Patient 3 by exposing private body care in the presence of another patient. Findings: A review of Patient 3’s face sheet, undated, indicated a start of care date of February 26, 2020, with a recertification period of March 26, 2026, to May 24, 2026. Patient 3 had diagnoses that included presence of a urogenital implant (a medical device placed in the urinary system to help drain urine from the body), unspecified lack of expected normal physiological development in childhood (the person did not grow or develop physically the way a child would normally do, but the exact reason was not known), and unspecified disorder of psychological development in childhood (a person had difficulties with mental or emotional development in childhood, but the exact type of problem was not identified). During a home visit observation and interview on April 8, 2026, from 9:48 AM to 11 AM with a Licensed Vocational Nurse 1 (LVN 1) and Patient 3’s caregiver (CG), LVN 1 entered the B&C and greeted Patient 3. Patient 3 repeated the greeting back to LVN 1. LVN 1 asked Patient 3 how he was doing and if he had any pain. Patient 3 repeated the questions back to LVN 1 and then stated in a repetitious manner, “I be good, I be good.” LVN 1 reassured Patient 3 that she knew Patient 3 would be good. Patient 3 was seated on a couch in the front living room area next to the front door of the B&C facility. Patient 3 was wearing a long sleeve shirt, long elastic‑waisted sweatpants, and shoes. The B&C facility was a residential home with an open floor plan. The front living room, family room, and kitchen were separated by a wall with a large cut‑out, creating a pony wall at the bottom and providing a clear view from the living room into the family room and vice versa. In the family room, a female patient was seated on a couch positioned up against the pony wall. The female patient had turned herself to watch, over the pony wall and through the large wall cut‑out, the proceedings happening in the living room with Patient 3 and LVN 1. LVN 1 proceeded with a body assessment of Patient 3. LVN 1 pulled Patient 3’s shirt up and elastic waistband down, exposing Patient 3’s lower abdomen. LVN 1 placed her stethoscope (a medical tool that lets a nurse listen to sounds inside the body) on various locations of the lower abdomen to listen for bowel sounds in Patient 3’s gut. LVN 1 replaced Patient 3’s shirt and elastic waistband and stated to Patient 3 that she was going to check Patient 3’s urinary device. Patient 3 repeated LVN 1’s words back to her. LVN 1 pulled Patient 3’s elastic waistband down, exposing the area just above the genitals to visualize Patient 3’s urinary device. LVN 1 replaced the elastic waistband and explained to Patient 3 that she would be cleaning and replacing the gauze for his urinary device. Patient 3 stated in a repetitious manner, “I be good, I be good.” LVN 1 again reassured Patient 3 that she knew he would be good. The female patient in the family room continued to watch what was happening in the living room. LVN 1 pulled Patient 3’s elastic waistband down, exposing the area just above the genitals, and cleaned Patient 3’s urinary device and replaced the gauze. In a continued interview with Patient 3’s CG, and after LVN 1 had completed Patient 3’s cares, Patient 3’s CG confirmed that Patient 3 had his own bedroom, which he shared with a roommate who was currently attending his day program. Patient 3’s CG stated the front door located adjacent to Patient 3 was the main entrance and exit for everyone coming and going from the B&C facility. LVN 1 stated she had not provided Patient 3 with personal respect and privacy and should have provided Patient 3’s nursing cares in Patient 3’s bedroom with the door closed. During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and the Director of Patient Care Services Designee (DPCSD) on April 8, 2026, at 2:44 PM, the Admin/DPCS stated LVN 1 did not provide Patient 3 with respect or visual and auditory (hearing) privacy. The Admin/DPCS stated LVN 1 should have provided Patient 3’s nursing cares in Patient 3’s bedroom with the door closed. The Admin/DPCS stated, “she expected her nurses to protect the privacy of the patients, especially the most vulnerable.” A review of the agency’s policy and procedure (P&P) titled, “Home Care Patients’ Rights and Responsibilities,” dated April 2010, indicated, “PURPOSE: To delineate the rights and responsibilities of the patients receiving home health services from the agency. To ensure that patient’s rights & responsibilities are respected and protected by those providing care to the patients of the agency. POLICY: Home Care patients and their caregivers have a right to mutual respect and dignity. … As a Patient of the agency, you have the right to: … Be treated with consideration, respect and full recognition of your dignity and individuality by trained professional staff. … Have your person and property treated with respect, privacy, including visual and auditory privacy, and security. …””

“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 an observation, interview, and record review, the agency failed to ensure a review of all the medications the patients were taking was conducted for two of seven sampled patients (Patients 2 and 3) when the Medication Profile (MP), indicated: 1. For Patient 2: The MP indicated Trelegy Ellipta (a medication to make breathing easier), 100 mcg (micrograms-a unit of measurement)/62.5 mcg/25 mcg inhaler, inhale one puff by mouth, once daily and Patient 2’s daughter stated the physician had increased the dose to 200 mcg/62.5 mcg/25 mcg, inhale one puff by mouth, once daily. Patient 2’s daughter stated Patient 2 had been receiving the increased dose since February 16, 2026. The MP also indicated phenazopyridine HCL (hydrochloride-a medication used to relieve urinary pain, burning, urgency, and discomfort caused by infections, injury, or surgery), 200 mg (milligrams-a unit of measurement), one tablet, as needed for painful urination. Patient 2’s daughter stated she had put this medication on hold and had explained to the Skilled Nurse (SN) on March 31, 2026, that she was holding the medication until Patient 2 had a urinalysis (a diagnostic test that examines a sample of urine for bacteria) and had her visit with the physician pending for April 9, 2026. 2. For Patient 3, the MP indicated ferrous sulfate (a nutritional supplement), 325 mg, give one tablet once daily, while the pharmacy label indicated take one tablet by mouth twice daily. The MP also indicated metoprolol succinate ER (extended release—a medication to lower blood pressure), 50 mg, give one tablet daily, and the pharmacy label indicated metoprolol succinate ER, 25 mg, give one tablet daily. Patient 3’s caregiver (CG) stated Patient 3 had been receiving the medications as directed on the pharmacy label at least since December 2, 2025. These failures had the potential to cause Patients 2 and 3 to suffer ineffective drug therapy, significant side effects and noncompliance with drug therapy. Findings: 1. A review of Patient 2’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of December 23, 2025, with a recertification period of February 21, 2026, to April 21, 2026. Patient 2 had diagnoses that included urinary tract infection and chronic obstructive pulmonary disease (a progressive, long-term lung disease that makes breathing difficult). During a home visit and interview on April 7, 2026, at 10:04 AM with Patient 2’s daughter, Patient 2’s daughter explained that she did not keep Patient 2’s pill bottles and boxes at Patient 2’s house because Patient 2 became confused easily and would take the pills randomly. Patient 2’s daughter stated she left Patient 2’s breathing treatment medications in Patient 2’s home because Patient 2 did not recognize those as medications. Patient 2’s daughter explained that she would fill little clear plastic containers with the pills Patient 2 needed for the week and hide them in Patient 2’s house, then would come over to the house and administer the medication to Patient 2 at the appropriate time. Patient 2’s daughter explained that she could not use a pill dispensing container marked Monday, Tuesday, Wednesday, etcetera, because Patient 2 knew what that was and would take all the medication contained within it. Patient 2’s daughter stated the SN would visit once a week and she would only bring a pill bottle to Patient 2’s house at the SN visit if there was a change in medication. Patient 2’s daughter stated the SN would not be able to check the MP against the pill bottles and boxes at her visit because they were not in Patient 2’s house. During an observation and interview on April 7, 2026, from 10:18 AM, to 10:33 AM with Patient 2’s daughter, Patient 2’s breathing treatment packages, available in the home, were compared with Patient 2’s most current MP. a. The MP indicated Trelegy Ellipta, 100 mcg/62.5 mcg/25 mcg inhaler, inhale one puff by mouth, once daily and Patient 2’s daughter stated the physician had increased the dose to 200 mcg/62.5 mcg/25 mcg, inhale one puff by mouth, once daily. Patient 2’s daughter stated Patient 2 had been receiving the increased dose since February 16, 2026. b. The MP indicated phenazopyridine HCL 200 mg, one tablet, as needed for painful urination. Patient 2’s daughter stated she had put this medication on hold and had explained to the SN on March 31, 2026, that she was holding the medication until Patient 2 had a urinalysis and had her visit with the physician pending for April 9, 2026. A review of Patient 2’s SN visit note dated February 27, 2026, indicated, “No changes in the medications.” A review of Patient 2’s Resumption of Care Assessment (ROC), dated March 25, 2026, conducted by a Registered Nurse (RN), the medication reconciliation section indicated Trelegy Ellipta, 100 mcg/62.5 mcg/25 mcg inhaler not the increased dose of Trelegy Ellipta, 200 mcg/62.5 mcg/25 mcg inhaler started on February 16, 2026. A review of Patient 2’s SN visit note dated March 31, 2026, indicated, “No changes in the medications.” During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and the Director of Patient Care Services Designee (DPCSD) on April 8, 2026, at 2:23 PM, the Admin/DPCS stated it was her expectation that the SN reconciled the patients’ actual medication bottles and packages against the medication profile at every visit. The DPCSD stated the SN should have called the office and informed her about Patient 2’s daughter keeping the medication bottles and packages in her home instead of Patient 2’s home so she could have addressed the situation. The DPCSD stated the SN should have called the physician about Patient 2’s daughter holding the phenazopyridine HCL and then given report to her, so the appropriate orders were obtained and the care plan updated, which did not happen. The Admin/DPCS confirmed that the SNs did not follow the proper protocol for reconciling Patient 2’s medications. 2. A review of Patient 3’s face sheet, undated, indicated a start of care date of February 26, 2020, with a recertification period of March 26, 2026, to May 24, 2026. Patient 3 had diagnoses that included hypertensive heart disease with heart failure (structural and functional heart damage caused by long-term high blood pressure, resulting in the heart’s inability to pump efficiently). During a home visit and interview on April 8, 2026, from 10:30 AM to 10:45 AM with a Licensed Vocational Nurse (LVN 1) and Patient 3’s CG, an observation of Patient 3’s actual medication bottles available in the home were compared with Patient 3’s most current MP. a. The MP indicated ferrous sulfate, 325 mg, give one tablet once daily, and the pharmacy label indicated take one tablet by mouth twice daily. b. The MP indicated metoprolol succinate ER, 50 mg, give one tablet daily, and the pharmacy label indicated metoprolol succinate ER, 25 mg, give one tablet daily. Patient 3’s CG stated Patient 3 had been receiving the medications as directed on the pharmacy label at least since December 2, 2025. LVN 1 stated she reconciled the actual medication bottles and packages against the MP at every visit, and she had missed these two errors for at least the past four months. During an interview with the Admin/DPCS and DPCSD on April 8, 2026, at 2:44 PM, the Admin/DPCS stated LVN 1 did not follow the proper protocol for reconciling Patient 3’s medications, which led to the two medication errors on Patient 3’s MP. A review of the agency’s policy and procedure (P&P) titled, “Comprehensive Assessment,” dated April 2010, indicated, “PURPOSE: … To ensure that an assessment is performed appropriate to the patient’s needs and the care and/or services provided by the organization. … POLICY: … The comprehensive assessment shall include 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 non-compliance with drug therapy. The comprehensive assessment must be updated and revised, including the appropriate OASIS [Outcome and Assessment Information Set--a standardized, mandatory data collection tool used by Medicare-certified home health agencies to assess patient functional status, plan care, and determine reimbursement] (ROC for Resumption of Care after an acute stay or SNF [Skilled Nursing Facility] admission, RECERT for Recertification) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status. … PROCEDURE: … The comprehensive assessment: … Review of prescribed, over-the-counter medications and herbal supplements, including Potential/actual drug interactions, Duplicative drug therapy, Potential adverse effects, Significant side effects and adverse effects, Noncompliance with drug therapy. … Dictated Medication Profile are reviewed for accuracy and completeness by the appropriate licensed staff. A copy of the medication profile is provided to the assigned clinicians. The assigned clinicians will provide the patient with a copy of the Medication Profile for reference and training purposes. …” A review of the agency’s P&P titled, “Medication and Treatment Orders,” dated March 17, 2017, indicated, “PURPOSE: To ensure that all medication and treatment orders are administered as prescribed by a licensed practitioner within his/her scope of practice. POLICY: … Medication review/reconciliation must be performed and documented during each SNV [Skilled Nursing Visit].””

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview, and record review, the agency failed to obtain physician’s orders for one of seven sampled patients (Patient 1) when heart rate (pulse rate) reporting parameters of “Parameters to Report to Supervisor: … Pulse Rate: Above 110 [bpm--beats per minute] or Below 50 [bpm]” were documented on Patient 1’s “Home Health Aide Care Plan,” dated February 6, 2026, to April 6, 2026, and April 7, 2026, to June 5, 2026, and there was no evidence of a physician’s order for the documented reporting parameters for heart rate. This failure had the potential to cause missed changes in Patient 1’s heart rate due to the lack of required physician orders, resulting in reduced physician oversight and delayed clinical intervention. Findings: A review of Patient 1’s face sheet (a document that gives a summary of patient’s information), undated, indicated a start of care date of February 6, 2026, with a certification period of February 6, 2026, to April 6, 2026. Patient 1 had diagnoses that included hypertensive heart disease (heart problems caused by long‑term high blood pressure). During a home visit and interview on April 7, 2026, from 12 PM to 1 PM with CHHA 1 and Patient 1’s daughter‑in‑law, CHHA 1 took Patient 1’s heart rate and stated it was 50 bpm, which was a little low but normal for Patient 1. CHHA 1 reviewed her home health aide care plan, confirmed the reporting parameters were “Parameters to Report to Supervisor: … Pulse Rate: Above 110 [bpm] or Below 50 [bpm],” and stated Patient 1’s heart rate was 50 bpm, so it did not need to be reported. A review of Patient 1’s “Home Health Aide Care Plan,” dated February 6, 2026, to April 6, 2026, and April 7, 2026, to June 5, 2026, indicated, “Parameters to Report to Supervisor: … Pulse Rate: Above 110 [bpm] or Below 50 [bpm].” A review of Patient 1’s physician’s orders from February 6, 2026, to April 8, 2026, showed no documented physician’s order for “Parameters to Report to Supervisor: … Pulse Rate: Above 110 [bpm] or Below 50 [bpm].” A review of Patient 1’s nursing care plan dated February 6, 2026, to April 6, 2026, and April 7, 2026, to June 5, 2026, signed by the physician turning the care plan into physician orders, indicated: “SN to observe for progression/decline in functional status and report any significant findings to PCP [Primary Care Physician]. SN [Skilled Nurse] to report to MD if the following condition occurs: … PR [pulse rate-heart rate] above 100 [bpm] or below 60 [bpm].” During an interview with the Administrator/Director of Patient Care Services (Admin/DPCS) and the Director of Patient Care Services Designee (DPCSD) on April 8, 2026, at 2 PM, the Admin/DPCS confirmed there was no physician’s order for “Parameters to Report to Supervisor: … Pulse Rate: Above 110 [bpm] or Below 50 [bpm].” The Admin/DPCS stated that, based on the only physician’s order for heart rate reporting parameters in Patient 1’s care plan, CHHA 1 should have reported the 50 bpm because the rate was below 60 bpm as indicated on the physician’s order. A review of the agency’s policy and procedure (P&P) titled, “Medication and Treatment Orders,” dated March 17, 2017, indicated, “PURPOSE: To ensure that all medication and treatment orders are administered as prescribed by a licensed practitioner within his/her scope of practice. POLICY: No medication or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone or by fax and shall be signed by the patient’s attending physician or other licensed and legally authorized practitioner within his or her scope of practice within 30 working days. …””