Optima Care 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 agency failed to ensure essential clinical documents were provided for two of ten sampled patients (Patient 1 and 2), when their home clinical record binders did not contain their current plan of care (POC- a guide that lists their medical and emotional needs, including treatments, medications, and personal wishes, to ensure their care), including their most current Medication Profile (MP-a current list of all medications prescribed for a specific patient), while Patients 1 and 2 were receiving home health services. This failure had the potential to result in poor care coordination, unmanaged symptoms, and medication errors, placing Patients 1 and 2 at risk for unmet health goals and delays in timely clinicals interventions. 1. 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 August 19, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) from February 15, 2026, to April 15, 2026. Patient 1 had diagnoses which included type 2 diabetes mellitus (too much sugar stays in your blood) with diabetic chronic kidney disease (kidneys are slowly getting damaged and cannot clean the blood as well as they should, when high blood sugar lasts for many years) and unspecified cirrhosis of liver (when the liver gets hurt over and over again, and the healthy liver tissue is replaced by scar tissue and makes it harder for the liver to work properly). During a concurrent interview and record review, on April 14, 2026, at 10:45 AM, with the Registered Nurse (RN), in the presence of Patient 1 and Patient 1’s wife, in Patient 1’s home, the clinical record binder and the surrounding area were reviewed. Patient 1’s current POC, including the most recent MP, were not found in the binder or anywhere in the house. Both the RN and Patient 1 wife confirmed that these essential documents were not available. 2. A review of Patient 2’s face sheet indicated a start of care date of October 30, 2025, with a certification period from February 27, 2026, to April 27, 2026. Patient 2 had diagnoses which included atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications) and Lattice degeneration of retina (when the retina has thin weak spots and it can sometimes lead to a tear). During a concurrent interview and record review, on April 14, 2026, at 12:40 PM, with the License Vocational Nurse (LVN), in the presence of Patient 2, in Patient 2’s home, the clinical record binder and the surrounding area were reviewed. Patient 2’s current POC, including the most recent MP, were not found in the binder or anywhere in the house. Both the LVN and Patient 2 confirmed that these essential documents were not available. During an interview on April 16, 2026, at 3:30 PM, with the Director of Patient Care Services (DPCS), the DPCS stated that the visiting nurse and the case manager were responsible to ensure the current POC including the most recent MP, and other essential documents must be at the patient’s location and to be easily accessible. The DPCS further stated, maintaining an up-to-date POC and MP was crucial for effective care coordination, proper medication management, and timely clinical responses. Furthermore, the DPCS stated that it is also to ensure patients receive all services outlined in the POC. During a concurrent interview and record review on April 16, 2026, at 3:50 PM, with the DPCS, the DPCS reviewed the agency’s policy and procedure (P&P) titled “Admission Criteria and Process,” revised November 2020, which indicated, “PURPOSE. To establish standards and a process by which a patient can be evaluated and accepted for admission…. Once a patient is admitted to service, the organization is responsible for providing care and services within its financial and service capabilities, mission, and applicable law and regulations… 16. A. Each patient must receive a patient-specific comprehensive assessment that identifies the need for home care and that meets the patient’s medical, nursing, rehabilitative, social, and discharge planning needs. …”. The DPCS stated the agency did not follow the policy.”

“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 medication reconciliation (process to compare current medication order with what home medications patients are taking) was conducted for three of ten sampled patients (Patients 1, 2, and 4) when: For Patient 1: One medication that the patient was actively taking was not listed on the Medication Profile (MP—a current list of all medications prescribed for a specific patient) and One medication the patient was taking had discrepancies in instructions between the MP, the label on home medication bottle, and actual use at home. For Patient 2: One medication being taken by the patient was not indicated on the MP, and one medication that the patient was taking had discrepancies in strength between the MP and the label on home medication. For Patient 4: One medication the patient was not taking had discrepancies in instructions between the MP, the label on home medication bottle and actual use at home. These failures had the potential to cause ineffective drug therapy, significant side effects and noncompliance with drug therapy. 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 August 19, 2025, with a certification period (a specific timeframe during which a patient is eligible to receive hospice services) from February 15, 2026, to April 15, 2026. Patient 1 had diagnoses which included type 2 diabetes mellitus (too much sugar stays in your blood) with diabetic chronic kidney disease (kidneys are slowly getting damaged and cannot clean the blood as well as they should, when high blood sugar lasts for many years) and unspecified cirrhosis of liver (when the liver gets hurt over and over again, and the healthy liver tissue is replaced by scar tissue and makes it harder for the liver to work properly). During a home visit on April 14, 2026, at 10:55 AM with the Registered Nurse (RN), in the presence of Patient 1 and Patient 1’s wife, an observation of Patient 1’s actual medication bottles, which were available at home, were compared with Patient 1’s most current MP. During a concurrent observation and interview on April 14, 2026, at 11:05 AM, with the RN, the RN checked a bottle of metformin (prescription medicine used to high blood sugar level) ER (extended released- released over time) 500 mg (milligram-a unit of measure) to take 2 tablets by mouth daily. Patient’s 1’s MP had no indication of a physician’s order for metformin ER 500 mg to take 2 tablets by mouth daily. Patient 1’s wife verified that Patient 1’s bottle of metformin ER 500 mg had not been recorded on the MP. Patient 1’s wife stated, “I picked this medication from pharmacy a month ago, back in March this year.” During a continued observation and interview on April 14, 2026, at 11:10 AM, with the RN, the RN checked a bottle of Tacrolimus (a prescription medicine that acts like a “shield” to stop the body’s immune system from attacking transplanted organs) 1 mg capsules to take six capsules twice a day. Patient 2’s MP listed the order as Tacrolimus 1 mg, four capsules instead, to take twice a day. Patient 1’s wife stated that he (Patient 1) had been taking five capsules by mouth twice a day for at least a couple of months following a doctor’s appointment, back in February this year. 2. A review of Patient 2’s face sheet indicated a start of care date of October 30, 2025, with a certification period from February 27, 2026, to April 27, 2026. Patient 2 had diagnoses which included atrial fibrillation (a quivering or irregular heartbeat that can lead to blood clots, stroke, heart failure and other heart-related complications) and Lattice degeneration of retina (when the retina has thin weak spots and it can sometimes lead to a tear). During a home visit on April 14, 2026, at 12:45, with the Licensed Vocational Nurse (LVN), in the presence of Patient 2, in Patient 2’s home, an observation of Patient 2’s actual medications, which were available in the home, were compared with Patient 2’s most current MP. During a concurrent observation and interview on April 14, 2026, at 12:50 PM, with the LVN, the LVN checked a bottle of Lumigan eye drops solution (a prescription medicine in the form of eye drops used to treat high pressure inside the eye). LVN reviewed Patient 2’s MP and acknowledged there was no physician’s order for Lumigan eye drops solution on Patient 2’s MP. Patient 2 stated, “I [Patient 2] have been using Lumigan eye drop solution for the past six years, and my doctor knows about it.” During a continued concurrent observation and interview on April 14, 2026, at 12:55 PM, with the LVN, the LVN checked a bubble pack card (is a specialized, organized, and secure way for a pharmacy to package pills) of Xarelto (a prescription medication known as a blood thinner that helps treat and prevent dangerous blood )15 mg. The LVN reviewed Patient 2’s MP and confirmed that the order on Patient 2’s MP was written as Xarelto 10 mg. Patient 2 stated, “I [Patient 2] had been taking the new dose [Xarelto 15 mg] about 2 weeks already and my doctor is aware of it.” 3. A review of Patient 4’s face sheet indicated a start of care date of February 19, 2026, with a certification period from February 19, 2026, to April 19, 2026. Patient 4 had diagnoses which included hypothyroidism (a condition where the thyroid gland [a small, butterfly-shaped gland in your neck] is underactive and doesn’t make enough thyroid hormone) During a home visit on April 15, 2026, at 12:30 PM, with the Physical Therapy (PT), in the presence of Patient 4, in Patient 4’s home, an observation of Patient 4’s actual medications, which were available in the home, were compared with Patient 4’s most current MP. During a concurrent observation and interview on April 15, 2026, at 12:35 PM, with the PT, the PT checked a bottle of levothyroxine (a prescription medication used to treat hypothyroidism), 25 mcg (microgram-a unit of measure), with directions to “take 1–2 tablets by mouth in the morning.” Patient 4’s MP listed the order as levothyroxine 25 mcg tablet every morning, without specifying how many tablets Patient 4 should take. Patient 4 stated that she had been taking 1 tablet every morning on Monday, Wednesday, and Thursday, and 2 tablets every morning on Tuesday, Friday, Saturday, and Sunday. Patient 4 further stated that she had been following this regimen the entire time. During an interview on April 16, 2026, at 4:00 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the expectation for nurses and staff was to perform medication reconciliation according to the agency’s policy. The DPCS further stated medication reconciliation should be conducted at each visit and that the medication profile must be updated if there are any changes. During a concurrent interview and record review on April 16, 2026, at 4:10 PM, with the DPCS, the DPCS reviewed the agency’s policy and procedure (P&P) titled “Medication Reconciliation” revised November 2020. The P&P indicated, “PURPOSE. To define the use of the medication profile in evaluating a patient’s medication regimen, including over-the-counter (OTC) medications, nutrition supplements, herbal remedies, vitamins and minerals. POLICY. 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. PROCEDURE …3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile to evaluate the use of medications in the home setting. B. Using the medication profile to teach purpose of medication, dosages, routes, administration times, side effects, and contraindications… 4. Each patient will receive appropriate written material for specific medications he/she is receiving…”. The DPCS stated that the agency policy was not being followed.”