Golden Years Home Health, Inc.

“Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient’s eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This Condition is not met as evidenced by: Based on an interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Comprehensive Assessment of Patients as follows: The HHA clinicians (in general- nursing and physical therapy) complete an accurate medication profile (a list of patient’s active medications for one of seven sampled patients (Patient 1) by failing to: 1. Ensuring the HHA licensed Physical Therapist accurately recorded the medications that Patient 1 was taking upon admission. 2. Ensure the licensed nurses (in general) accurately recorded Patient 1’s active medications on the HHA medication profile. 3. Ensure the licensed nurses regularly monitor Patient 1’s medication to ensure it was accurate on the medication profile. 4. Ensure that Patient 1’s primary care physician (PCP) was notified that the medications orders at the Senior Living Facility and the medication orders for the HHA did not match. As a result, Patient 1 was placed at increased risk for medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and adverse medication reactions (unwanted undesirable effects that are possibly related to a drug) from the medications such as changes in blood pressures, changes in heart rate, that could lead to hospitalization and death. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily (written law) mandated compliance with Federal regulation for Comprehensive Assessment of patients to ensure the highest quality of care were being provided to patients certified to receive home health care and 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 an interview and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed for the HHA’s clinicians (in general- nursing and physical therapy) to ensure an accurate medication profile (a list of patient’s active medications) was conducted for one of seven sampled patients (Patient 1) by failing to: 1. Ensuring the HHA licensed Physical Therapist accurately recorded the medications that Patient 1 was taking upon admission. 2. Ensure the licensed nurses (in general) accurately recorded Patient 1’s active medications on the HHA medication profile. 3. Ensure the licensed nurses regularly monitored Patient 1’s medication to ensure it was accurate on the medication profile. 4. Ensure that Patient 1’s primary care physician (PCP) was notified that the medications orders at the Senior Living Facility and the medication orders for the HHA did not match. As a result, Patient 1 was placed at increased risk for medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and adverse medication reactions (unwanted undesirable effects that are possibly related to a drug) from the medications such as changes in blood pressures, changes in heart rate, that could lead to hospitalization and death. On 11/5/2025 at 11:15 a.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Director of Nursing Services (DPCS) and Administrator, related to the HHA’s failure to conduct a complete and accurate current medication reconciliation (the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency) and accurately reflected, updated, and implemented for the recertification period of one of 17 sampled patients (Patient 1). During a review of Patient 1’s Admission Record indicated Patient 1 was readmitted to HHA on 9/23/2025, with home health recertification period of 9/23/2025- 11/21/2025, with diagnosis of, but not limited to, epilepsy (a condition in the brain that can cause seizures [sudden, uncontrolled burst of electrical activity in the brain which can cause a variety of symptoms including confusion or disorientation, involuntary muscle movements, such as jerking, twitching, or stiffening, loss of consciousness or altered awareness]), hypertensive heart disease (a condition where the heart muscle is damaged or enlarged due to prolonged high blood pressure [hypertension]), heart failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs) and history of falling. During a review of Patient 1’s recertification assessment dated 9/23/2025, Patient 1’s recertification assessment indicated that Patient 1 was taking carvedilol (a prescription medication that is primarily used to treat conditions affecting the heart and blood vessels) 6.25 milligrams (mg, unit of is a unit of weight or mass) tablet by mouth twice daily, docusate sodium (a stool softener, also known as an emollient laxative, used to treat occasional constipation) 100 mg capsule by mouth at night, acetaminophen (also known as Tylenol, a medication used to treat pain) 325 mg., take two tablets by mouth every four hours as needed for moderate pain (four to six on a scale of 10), acetaminophen 500 mg., one tablet by mouth every four hours as needed for mild pain (one - three on a scale of 1-10), and magnesium hydroxide (a laxative that treats occasional constipation) 400 mg., per 5 milliliter (ml, a unit of volume) 30 ml by mouth every twenty-four hours as needed for bowel management. During a review of Patient 1’s medication profile (a comprehensive record of all the medications that a patient is currently taking) for October 2025 at the Senior Living Facility, where Patient 1 resided. Patient 1’s medication profile indicated that Patient 1 was taking carvedilol 12.5 mg., tablet twice daily and docusate sodium 100 mg., capsule by mouth two times a day as needed for constipation. Patient 1’s medication profile did not indicate that Patient 1 had physicians orders or was receiving acetaminophen 325 mg., 2 tablets by mouth every four hours as needed for moderate pain, acetaminophen 500 mg., one tablet by mouth every four hours as needed for mild pain, and magnesium hydroxide 400 mg/5 ml 30 ml by mouth every twenty-four hours as needed for bowel management. During a review of Patient 1’s HHA’s Patient Medication Record, dated 9/27/2025 entered into the clinical record by Registered Nurse 1, Patient Medication Record, indicated that Patient 1 was taking carvedilol 6.25 mg., tab by mouth twice daily, docusate sodium 100 mg., capsule by mouth at night, acetaminophen 325 mg., two tablets by mouth every four hours as needed for moderate pain, acetaminophen 500 mg., one tablet by mouth every four hours as needed for mild pain, and magnesium hydroxide 400mg/5ml, 30 ml., by mouth every twenty-four hours as needed for bowel management. During a review of Patient 1’s HHA Skilled nursing discharge summary dated 10/30/2025 indicated that Patient was discharged with continued medication orders for carvedilol 6.25 mg tab by mouth twice daily, docusate sodium 100 mg capsule by mouth at night, acetaminophen 325 mg 2 tablets by mouth every four hours as needed for moderate pain (4-6 on a scale of 10), acetaminophen 500 mg 1 tablet by mouth every four hours as needed for mild pain (1-3 on a scale of 1-10), and magnesium hydroxide 400mg/5ml 30ml by mouth every 24 hours as needed for bowel management. During an interview and concurrent record review on 11/4/2025 at 10:30 am., of Patient 1’s admission reassessment dated 9/23/2025, medication profile dated 9/27/2026, and discharge summary dated 10/30/2025, and Senior Living Facility medication profile for October 2025, with the Director of Patient Care Services (DPCS), the DPCS stated that the medications the HHA ordered for Patient 1 did not match the medications that Patient 1 was actually taking. The DPCS stated that Patient 1 had received carvedilol 6.25 mg., twice daily but Patient 1 was taking 12.5 mg., daily. DPCS stated the HHA records indicated that Patient 1 was taking docusate sodium 100mg daily at night and the patient but that patient was receiving docusate sodium 100mg capsule by mouth two times a day as needed for constipation. The DPCS further indicated that Patient 1 was not receiving acetaminophen 325 mg 2 tablets by mouth every four hours as needed for moderate pain (4-6 on a scale of 10), acetaminophen 500 mg 1 tablet by mouth every four hours as needed for mild pain (1-3 on a scale of 1-10), or magnesium hydroxide 400mg/5ml 30ml by mouth every 24 hours as needed for bowel management. During an interview on 11/4/2025 at 10:54 am, Licensed Vocational Nurse 1 (LVN1) stated that he was seeing Patient 1 o during the time period of 10/2/2025 through 10/21/2025 (total of 4 visits). LVN1 stated that while he was providing care for Patient 1 that he would ask about any changes in medication but that he did not compare the medication list of the HHA to the list of the Senior Living Center. LVN1 also stated that he did not compare the HHA list of medications to the bottles of the medications that were being used to administer medications to Patient 1. LVN 1 was unaware of any medication discrepancies. During an interview on 11/4/2025 at 11:50 am, Registered Nurse 1 (RN 1) stated that she saw Patient 1 upon the start of nursing care on 9/26/2026 and at the end of nursing care on 10/30/2025. RN 1stated that she did not see the bottles that were being used to administer Patient 1’s medications or receive a copy of the medication profile, but that the Senior Facility Living Center staff read the medication orders they had file to her. RN 1 did not know that there were discrepancies between the HHA orders and the medications and doses that Patient 1 was receiving. During an interview on 11/5/2025 at 9:22 am, DPCS stated that the HHA does a medication reconciliation to compare the medications that a patient is taking to the medication orders of the HHA in order to ensure there are no issues with medications such as compliance or medications errors. DPCS stated that the medication reconciliation should be done every visit and that any changes or discrepancies should be reported to the HHA so that they can contact the physician for orders. DPCS stated that for Patient 1, the different doses in carvedilol could have potential negative outcomes such as Patient 1’s medical condition can exacerbate, patient can end up in the hospital, if the dose is too high then the blood pressure will drop and the heart rate can be affected. A review of the facility’s policy and procedures titled, “Contents of the Clinical Record,” dated 2009, indicated that each patient’s medical record will include, “current medication profile, including prescription and nonprescription medications, dose, strength, frequency, route, date and time of administration and new, change or discontinued medication.” A review of the facility’s policy and procedures titled, “Medication Profile,” dated 2009, indicated that, “patients receiving medications will have a current, accurate medication profile in the clinical record.” The policy further indicated that, “upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen,” and that, “deviations in the medications as ordered will be documented in the clinical notes, and the physician (or allowed practitioner) will be notified.” A review of the facility’s undated policy and procedures titled “Medication Reconciliation,” indicated that the following should be performed at every visit, “compare medications bottles to the medication profile,” “reconcile any discrepancies between the medication bottes and the medication profile.” The policy further indicated that the HHA will, “contact the physician, if needed, to obtain new orders.” . During a review of Patient 1’s Admission Record indicated Patient 1 was readmitted to HHA on 9/23/2025, with home health recertification period of 9/23/2025- 11/21/2025, with diagnosis of, but not limited to, epilepsy (a condition in the brain that can cause seizures [sudden, uncontrolled burst of electrical activity in the brain which can cause a variety of symptoms including confusion or disorientation, involuntary muscle movements, such as jerking, twitching, or stiffening, loss of consciousness or altered awareness]), hypertensive heart disease (a condition where the heart muscle is damaged or enlarged due to prolonged high blood pressure [hypertension]), heart failure (a condition where the heart cannot pump blood effectively enough to meet the body’s needs) and history of falling. During a review of Patient 1’s recertification assessment dated 9/23/2025, Patient 1’s recertification assessment indicated that Patient 1 was taking carvedilol (a prescription medication that is primarily used to treat conditions affecting the heart and blood vessels) 6.25 milligrams (mg, unit of is a unit of weight or mass) tablet by mouth twice daily, docusate sodium (a stool softener, also known as an emollient laxative, used to treat occasional constipation) 100 mg capsule by mouth at night, acetaminophen (also known as Tylenol, a medication used to treat pain) 325 mg., take two tablets by mouth every four hours as needed for moderate pain (four to six on a scale of 10), acetaminophen 500 mg., one tablet by mouth every four hours as needed for mild pain (one - three on a scale of 1-10), and magnesium hydroxide (a laxative that treats occasional constipation) 400 mg., per 5 milliliter (ml, a unit of volume) 30 ml by mouth every twenty-four hours as needed for bowel management. During a review of Patient 1’s medication profile (a comprehensive record of all the medications that a patient is currently taking) for October 2025 at the Senior Living Facility, where Patient 1 resided. Patient 1’s medication profile indicated that Patient 1 was taking carvedilol 12.5 mg., tablet twice daily and docusate sodium 100 mg., capsule by mouth two times a day as needed for constipation. Patient 1’s medication profile did not indicate that Patient 1 had physicians orders or was receiving acetaminophen 325 mg., 2 tablets by mouth every four hours as needed for moderate pain, acetaminophen 500 mg., one tablet by mouth every four hours as needed for mild pain, and magnesium hydroxide 400 mg/5 ml 30 ml by mouth every twenty-four hours as needed for bowel management. During a review of Patient 1’s HHA’s Patient Medication Record, dated 9/27/2025 entered into the clinical record by Registered Nurse 1, Patient Medication Record, indicated that Patient 1 was taking carvedilol 6.25 mg., tab by mouth twice daily, docusate sodium 100 mg., capsule by mouth at night, acetaminophen 325 mg., two tablets by mouth every four hours as needed for moderate pain, acetaminophen 500 mg., one tablet by mouth every four hours as needed for mild pain, and magnesium hydroxide 400mg/5ml, 30 ml., by mouth every twenty-four hours as needed for bowel management. During a review of Patient 1’s HHA Skilled nursing discharge summary dated 10/30/2025 indicated that Patient was discharged with continued medication orders for carvedilol 6.25 mg tab by mouth twice daily, docusate sodium 100 mg capsule by mouth at night, acetaminophen 325 mg 2 tablets by mouth every four hours as needed for moderate pain (4-6 on a scale of 10), acetaminophen 500 mg 1 tablet by mouth every four hours as needed for mild pain (1-3 on a scale of 1-10), and magnesium hydroxide 400mg/5ml 30ml by mouth every 24 hours as needed for bowel management. During an interview and concurrent record review on 11/4/2025 at 10:30 am., of Patient 1’s admission reassessment dated 9/23/2025, medication profile dated 9/27/2026, and discharge summary dated 10/30/2025, and Senior Living Facility medication profile for October 2025, with the Director of Patient Care Services (DPCS), the DPCS stated that the medications the HHA ordered for Patient 1 did not match the medications that Patient 1 was actually taking. The DPCS stated that Patient 1 had received carvedilol 6.25 mg., twice daily but Patient 1 was taking 12.5 mg., daily. DPCS stated the HHA records indicated that Patient 1 was taking docusate sodium 100mg daily at night and the patient but that patient was receiving docusate sodium 100mg capsule by mouth two times a day as needed for constipation. The DPCS further indicated that Patient 1 was not receiving acetaminophen 325 mg 2 tablets by mouth every four hours as needed for moderate pain (4-6 on a scale of 10), acetaminophen 500 mg 1 tablet by mouth every four hours as needed for mild pain (1-3 on a scale of 1-10), or magnesium hydroxide 400mg/5ml 30ml by mouth every 24 hours as needed for bowel management. During an interview on 11/4/2025 at 11:50 am, Registered Nurse 1 (RN 1) stated that she saw Patient 1 upon the start of nursing care on 9/26/2026 and at the end of nursing care on 10/30/2025. RN 1stated that she did not see the bottles that were being used to administer Patient 1’s medications or receive a copy of the medication profile, but that the Senior Facility Living Center staff read the medication orders they had file to her. RN 1 did not know that there were discrepancies between the HHA orders and the medications and doses that Patient 1 was receiving. During an interview on 11/4/2025 at 10:54 am, Licensed Vocational Nurse 1 (LVN1) stated that he was seeing Patient 1 o during the time period of 10/2/2025 through 10/21/2025 (total of 4 visits). LVN1 stated that while he was providing care for Patient 1 that he would ask about any changes in medication but that he did not compare the medication list of the HHA to the list of the Senior Living Center. LVN1 also stated that he did not compare the HHA list of medications to the bottles of the medications that were being used to administer medications to Patient 1. LVN 1 was unaware of any medication discrepancies. During an interview on 11/5/2025 at 9:22 am, DPCS stated that the HHA does a medication reconciliation to compare the medications that a patient is taking to the medication orders of the HHA in order to ensure there are no issues with medications such as compliance or medications errors. DPCS stated that the medication reconciliation should be done every visit and that any changes or discrepancies should be reported to the HHA so that they can contact the physician for orders. DPCS stated that for Patient 1, the different doses in carvedilol could have potential negative outcomes such as Patient 1’s medical condition can exacerbate, patient can end up in the hospital, if the dose is too high then the blood pressure will drop and the heart rate can be affected. A review of the facility’s policy and procedures titled, “Contents of the Clinical Record,” dated 2009, indicated that each patient’s medical record will include, “current medication profile, including prescription and nonprescription medications, dose, strength, frequency, route, date and time of administration and new, change or discontinued medication.” A review of the facility’s policy and procedures titled, “Medication Profile,” dated 2009, indicated that, “patients receiving medications will have a current, accurate medication profile in the clinical record.” The policy further indicated that, “upon admission to the organization, the admitting clinician will initiate a medication profile to document the current medication regimen,” and that, “deviations in the medications as ordered will be documented in the clinical notes, and the physician (or allowed practitioner) will be notified.” A review of the facility’s undated policy and procedures titled “Medication Reconciliation,” indicated that the following should be performed at every visit, “compare medications bottles to the medication profile,” “reconcile any discrepancies between the medication bottes and the medication profile.” The policy further indicated that the HHA will, “contact the physician, if needed, to obtain new orders.””