A and E Home Health Services, 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 observation, interview, and record review, the agency failed to ensure 1 of 7 staff members was knowledgeable about the location of the agency’s designated and alternate meeting location in case of emergencies. This failure had the potential for a delay in the overall agency communication and coordination of services for all 90 vulnerable patients at risk who received care from the agency. Findings: During an interview on February 11, 2026, at 3:15 PM, with Physical Therapist Assistant (PTA), while at Patient 3’s home, PTA stated that she does not know where the agency’s primary and alternate emergency meeting location was. PTA further stated that she has not been educated or done in-service training regarding emergency preparedness. During an Interview on February 12, 2026, at 12:30 PM, with the Administrator (ADMIN), ADMIN stated, “All staff should have been educated and in-serviced on emergency preparedness, PTA should know the designated and alternate meeting location in case of emergency.” During a follow up concurrent interview and record review on February 12, 2026, at 12:55 PM, with ADMIN, the agency’s policy and procedure (P&P) titled, “Skilled Nursing In-Service Education,” dated January 2024, was reviewed. The P&P indicated … “Purpose To ensure all skilled nursing staff maintain competency, clinical excellence, and compliance with federal, state, and agency regulations through structured in-service education. Scope: This policy applies to Registered Nurses (RNs), Licensed Practical/Vocational (LPNs/LVNs), Contract or PRN Skilled Nursing Staff 2. Mandatory Topics: The following topics must be covered at minimum annually (or per regulation) Infection prevention and control, OSHA and bloodborne pathogens, Emergency preparedness……” The Admin verified and confirmed that PTA has not completed agency’s ’s in-service emergency preparedness training, and this failure has the potential to place vulnerable patients at risk for delays in communication and coordination of services.”

“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 interview, and record review, the agency failed to ensure a medication reconciliation (a critical safety process of creating the most accurate list of a patient’s current medications including name, dosage, frequency, route, and expiration and comparing it against physician’s orders) was conducted for one of seven sampled patients (Patient 1) when one medication, Metformin (the primary medication used to treat diabetes by lowering high blood sugar levels), was found to be expired and available for use. The medication was noted to be 41 days past its expiration date at the time of the recertification survey. This failure had the potential to cause ineffective drug therapy to Patient 1, significant side effects and noncompliance with drug therapy. Findings: During a review of Patient 1’s face sheet (a document that gives a summary of patient’s information), indicated a start of care date of February 27, 2025, with a recertification period of December 24, 2025, to February 21, 2026. Patient 1 had diagnoses that included Type 2 diabetes mellitus (a chronic condition where the body cannot effectively use insulin). During a home visit on February 10, 2026, at 11:00 AM, Registered Nurse 1 (RN 1) and in the presence of Patient 1, an observation of Patient 1’s medications currently available at home were compared with Patient 1’s most current Medication Profile (MP-a comprehensive, up to date document summarizing a patient’s medications). During a concurrent observation and interview on February 10, 2026, at 11:15 AM, with RN 1, Patient 1’s medication Metformin was checked. The label on the medication container indicated, “(name of medication) Use before …EXP (expiration): 12/31/2025 (December 31, 2025-medication had been expired for 41 days).” During an interview on February 10, 2026, at 11:30 AM, with RN 1. RN 1 stated, “I should have checked the Metformin expiration date in my medication reconciliation check for patient 1, I did not check it.” The RN 1 verified and confirmed Metformin had been expired for 41 days. The RN 1 further stated administering expired Metformin will put Patient 1 at risk of ineffective blood glucose control. During a follow up interview and record review on February 11, 2026, at 12:30 PM with Administrator (ADMIN), the agency’s policy and procedure (P&P) titled, “Medication Administration & High -Risk Medications,” dated January 30, 2025, was reviewed. The P&P indicated …”Expired Medications in the Home health Setting I. Purpose. To ensure nurses properly identify, address, educate, and document issues related to expired medications in patient’s homes in compliance with: CMS Condition of Participation (Medication Management & Patient Safety), California Nursing Practice Act, Agency medication management Policy. II Learning Objectives, By the end of this training, staff will be able to: 1. Identify expired medications during home visits 2. Understand risks associated with expired drugs. 3. Implement appropriate nursing actions. 4. Educate patients and caregivers. 5. Properly document findings and interventions.” The ADMIN stated that RN 1 should have checked the expiration date of the Metformin for Patient 1. ADMIN further verified and confirmed that Metformin has been expired for 41 days, and Patient 1 may not receive the intended dose, even if the correct dose are administered which can lead to poor blood glucose control and RN 1 did not follow the P&P by not checking expired Metformin for patient 1.”