Continuity Providers Healthcare, Inc.

“Condition of Participation: Patient rights. CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient’s rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This Condition is not met as evidenced by: Based on 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 ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Patient Rights was met as follows: 1. The HHA failed to treat one of seven sampled patients (Patient 3) as an individual with respect and ensure Patient 3’s dignity was maintained by delivering and providing skilled nursing services outside of the patient’s residence. This failure indicates a lack of adherence to patient-centered care standards and policies regarding respectful treatment and posed a risk of affecting Patient 3’s physical and emotional well-being. (Refer to G428) 2. The HHA failed to ensure one of seven sampled patients (Patient 3) was informed of all aspects of the planned care and services, and the way the care and services will be delivered by the HHA nursing staff. This failure resulted in the violation of Patient 3’s rights to be informed of the care and treatment furnished by the HHA as identified in the plan of care (POC, a detailed, written document outlining the services and supporting an individual needs to meet their healthcare goals). (Refer to G434) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Patient Rights to ensure highest quality health care is provided to patients assessed to receive home health services.”

“Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This Condition is not met as evidenced by: Based on interview and record review, the home health agency (HHA, an organization that delivers skilled nursing and other therapeutics services to a patient at home) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding Infection Prevention and Control was met as follows: The HHA nursing staff failed to provide a safe, sanitary environment to help prevent the spread of infection, for one of seven sampled patients (Patient 3), when the registered nurse (RN 1) administered IV (intravenous, or into the vein) antibiotic infusion (the administration of medication directly into a patient’s vein via a catheter to treat severe or resistant bacterial infections) through a PICC line (or peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in your arm and guided into a large vein near your heart) in the parking driveway outside the patient’s residence. This deficient practice had the potential to result in Patient 3 acquiring CLABSI (Central Line-Associated Bloodstream Infections, a serious infection that occurs when germs [usually bacteria or fungi] enter the bloodstream directly through a central venous catheter or a central line) which could negatively affect patient’s health and quality of life. (Refer to G682) The cumulative effect of this systemic practice resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for Infection Prevention and Control to ensure highest quality health care is provided to patients assessed to receive home health services.”

“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 interview, and record review, the home health agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) nursing staff failed to provide a safe, sanitary environment to help prevent the spread of infections, for one of seven sampled patients (Patient 3). The registered nurse (RN 1) administered IV (intravenous, or into the vein) antibiotic infusion (the administration of medication directly into a patient’s vein via a catheter to treat severe or resistant bacterial infections) thru PICC line (or peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in your arm and guided into a large vein near your heart) in the parking driveway outside the patient’s residence. This deficient practice had the potential to result in Patient 3 acquiring CLABSI (or Central Line-Associated Bloodstream Infections, a serious infection that occurs when germs [usually bacteria or fungi] enter the bloodstream directly through a central venous catheter or a central line) which could negatively affect patient’s health and quality of life. During a closed record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 3’s start of care (SOC) date was 3/13/2026, with a diagnosis that includes osteomyelitis (an infection in a bone), age-related osteoporosis (a disease that decreases bone mineral density and mass), and long term use of antibiotics. The Face Sheet further indicated that Patient 3 was discharged on 3/23/2026 due to being transferred to another HHA. During a closed record review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and supporting an individual needs to meet their healthcare goals) for the certification period starting from 3/13/2026 to 6/10/2026, the POC included an order for the skilled nurse to visit starting on week of 3/13/2026 and ending on 4/19/2026 as authorized, for skilled assessment and observation, vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse, and respiratory [breathing] rate) every visit, checked medication status for patient’s response to medications, medication compliance and effectiveness, and to prepare and administer IV infusion of Piperacillin/Tazobactam (a strong, broad-spectrum antibiotic medication to treat severe infection) 13.5 gram (gm, a unit of measurement) per NS (normal saline, a sterile mixture of water and salt) 310 milliliter (ml, a unit of volume), administer 3.375 gm via PICC line every 6 hours with Curlin pump (a portable infusion pump used to administer fluids, medications, or liquid nutrition directly into a patient’s body), and change bag every 24 hours as directed by MD (medical doctor). During a review of Patient 3’s clinical record titled, High Tech Skilled Nursing Note, dated 3/22/2026, the Skilled Nursing note indicated RN staff prepared and administered Zosyn (brand medication name for Piperacillin/Tazobactam) 3.375 gm via PICC line with Curlin pump. During a phone interview, on 5/27/2026 at 9:24 a.m., with RN 1 stated, she visited Patient 3 on 3/22/2026 and administered IV Zosyn through a PICC line. Because she was unable to find parking, RN 1 stated she checked the patient’s vital signs and gave the IV medication outside, along the driveway near the apartment garage. RN 1 stated she could not find any rules or regulations prohibiting or making it illegal to administer IV medications via a PICC line outside the patient’s home. According to CDC: https://www.cdc.gov Administering medications in a non-clinical, outdoor setting (parking driveway) via central line (PICC) is high risk. Strict adherence to aseptic non-touch technique, rigorous infection, control, and mechanical safety standards is required to prevent life threatening complications like catheter related blood stream infections (CLABSI) and air embolism. During an interview, on 5/28/2026 at 1:40 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS) stated, IV medications should not be given outside or in the street. The ADM/DPCS stated administering IV medications, especially via a PICC line, in places like a parking driveway exposes patients to dust and contaminants, increasing the risk of catheter-related bloodstream infection. The ADM/DPCS stated and acknowledged the findings. During a review of the agency’s policy and procedure (P&P) titled, Infection Control Plan, revised November 2022, the P&P indicated Continuity Providers Healthcare, Inc is committed to reducing the risk of acquisition and transmission of health care associated infections (HAIs). Recognized prevention and control mechanisms will be implemented for planning, surveillance identification, prevention/controls, and reporting procedures. Continuity Providers Healthcare, Inc will educate all personnel on infection control policies, procedures and their responsibilities for implementation as contained throughout this section.”

“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 interview and record review, the home health agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure the patient has the right to be treated with dignity and respect for one of seven sampled patients (Patient 3). Patient 3’s plan of care (POC) included for the skilled nurse 1 (RN1) to prepare and administer intravenous (IV) infusion of Piperacillin/Tazobactam (a strong, broad-spectrum antibiotic medication to treat severe infection) 13.5 grams, per NS (normal saline, a sterile mixture of water and salt) 310 milliliter, administer 3.375 gm via peripherally inserted central catheter (PICC) line every 6 hours with Curlin pump . RN 1 administered the medication via PICC line in an uncontrolled environment (parking driveway) outside the patient’s residence. This failure resulted in the non-adherence/violation of the patient’s rights to be treated with dignity and respect of patient’s privacy. During a closed record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 3’s start of care (SOC) date was 3/13/2026, with a diagnosis that includes osteomyelitis (an infection in a bone), age-related osteoporosis (a disease that decreases bone mineral density and mass), and long term use of antibiotics. The Face Sheet further indicated that Patient 3 was discharged on 3/23/2026 after transfer to another HHA. During a closed record review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and supporting an individual needs to meet their healthcare goals) for the certification period starting from 3/13/2026 to 6/10/2026, the POC included an order for the skilled nurse to visit starting on week of 3/13/2026 and ending on 4/19/2026 as authorized, for skilled assessment and observation, vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse, and respiratory [breathing] rate) every visit, checked medication status for patient’s response to medications, medication compliance and effectiveness, and to prepare and administer IV infusion of Piperacillin/Tazobactam (a strong, broad-spectrum antibiotic medication to treat severe infection) 13.5 gram (gm, a unit of measurement) per NS (normal saline, a sterile mixture of water and salt) 310 milliliter (ml, a unit of volume), administer 3.375 gm via PICC line (or peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in your arm and guided into a large vein near your heart) every 6 hours with Curlin pump (a portable infusion pump used to administer fluids, medications, or liquid nutrition directly into a patient’s body), and change bag every 24 hours as directed by MD (medical doctor). During a review of Patient 3’s clinical record titled, High Tech Skilled Nursing Note, dated 3/22/2026, the Skilled Nursing note indicated staff RN performed vital signs, prepared and administered Zosyn (brand medication name for Piperacillin/Tazobactam) 3.375 gm via PICC line with Curlin pump. During a phone interview, on 5/27/2026 at 9:24 a.m., with the registered nurse (RN 1), RN 1 stated that she visited Patient 3 on 3/22/2026 and administered IV Zosyn through a PICC line. Because she was unable to find parking, RN 1 stated she checked the patient’s vital signs and gave the IV medication outside, along the driveway near the apartment garage. RN 1 stated she could not find any rules or regulations prohibiting or making it illegal to administer IV medications via a PICC line outside the patient’s home. During a phone interview on 05/27/2026 at 2:18 p.m., Patient 3 described her experience during the nurse visit on 3/22/2026. Patient 3 stated that she was neither informed nor notified that RN 1 would be checking her vital signs and administering IV medications outside her home, specifically in the parking driveway. Patient 3 stated that her preferred language is Spanish and that she barely understands English. Patient 3 explained that on 03/22/2026, she received a call from RN 1, who spoke to her in English and provided instructions. According to Patient 3, she understood these instructions as a request to come out of her house to sign some forms for the agency. Upon meeting RN 1 at the parking driveway, Patient 3 was surprised when RN 1 proceeded to administer the IV medication and checked her vital signs while she was standing next to RN 1’s vehicle. Patient 3 reported feeling traumatized by the experience of receiving an IV infusion outside her house where she was exposed to public view, expressing shock at the situation caused by the lack of privacy and concern over the lack of clear communication in her preferred language. During a phone interview, on 5/28/2026 at 9:57 a.m., with RN 1, RN 1 stated and explained that she consistently communicates with patient 3 in English and has never utilized interpreter services to facilitate communication in Spanish, Patient 3’s preferred language. When specifically asked whether she had confirmed Patient 3’s preferred language, RN 1 stated that she believed Patient 3 understands English. During an interview, on 5/28/2026 at 1:40 p.m. with the Administrator/Director of Patient Care Services (ADM/DPCS) stated that patients always have the right to be fully informed about the care and services they will receive delivered in a language that the patient preferred and understood and must always be treated with dignity and respect. The ADM/DPCS stated and acknowledged the findings. During a review of the agency’s policy and procedure (P&P) titled, Bill of Rights, revised November 2022, the P&P indicated each patient will be an active, informed participant in his/her plan of care. The patient Bill of Rights statement defines the right of the patient to the right of privacy, security, and respect of property and person. The organization shall provide verbal notice of the patient’s rights and responsibilities in the patient’s primary or preferred language and in a manner the individual understands.”

“Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to ensure one of seven sampled patients (Patient 3) was informed of all aspects of the planned care and services, and the way the care and services will be delivered by the HHA nursing staff. This failure resulted in the violation of Patient 3’s rights to be informed of the care and treatment furnished by the HHA as identified in the plan of care (POC). During a closed record review of Patient 3’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 3’s start of care (SOC) date was 3/13/2026, with a diagnosis that includes osteomyelitis (an infection in a bone), age-related osteoporosis (a disease that decreases bone mineral density and mass), and long term use of antibiotics. The Face Sheet further indicated that Patient 3 was discharged on 3/23/2026 after transfer to another HHA. During a closed record review of Patient 3’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and supporting an individual needs to meet their healthcare goals) for the certification period starting from 3/13/2026 to 6/10/2026, the POC included an order for the skilled nurse to visit starting on week of 3/13/2026 and ending on 4/19/2026 as authorized, for skilled assessment and observation, vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse, and respiratory [breathing] rate) every visit, checked medication status for patient’s response to medications, medication compliance and effectiveness, and to prepare and administer IV infusion of Piperacillin/Tazobactam (a strong, broad-spectrum antibiotic medication to treat severe infection) 13.5 gram (gm, a unit of measurement) per NS (normal saline, a sterile mixture of water and salt) 310 milliliter (ml, a unit of volume), administer 3.375 gm via PICC line (or peripherally inserted central catheter, a long, thin, flexible tube inserted into a vein in your arm and guided into a large vein near your heart) every 6 hours with Curlin pump (a portable infusion pump used to administer fluids, medications, or liquid nutrition directly into a patient’s body), and change bag every 24 hours as directed by MD (medical doctor). During a review of Patient 3’s clinical record titled, High Tech Skilled Nursing Note, dated 3/22/2026, the Skilled Nursing note indicated staff RN performed vital signs, prepared and administered Zosyn (brand medication name for Piperacillin/Tazobactam) 3.375 gm via PICC line with Curlin pump. During a phone interview, on 5/27/2026 at 9:24 a.m., with RN 1, RN 1 stated that she visited Patient 3 on 3/22/2026 and administered IV Zosyn through a PICC line. Because she was unable to find parking, RN 1 stated she checked the patient’s vital signs and gave the IV medication outside, along the driveway near the apartment garage. RN 1 stated she could not find any rules or regulations prohibiting or making it illegal to administer IV medications via a PICC line outside the patient’s home. During a phone interview on 05/27/2026 at 2:18 p.m., Patient 3 described her experience during the nurse visit on 03/22/2026. Patient 3 stated that she was neither informed nor notified that RN 1 would be checking her vital signs and administering IV medications outside her home, specifically in the parking driveway. Patient 3 stated that her preferred language was Spanish and that she barely understands English. Patient 3 explained that on 03/22/2026, she received a call from RN 1, who spoke to her in English and provided instructions. According to Patient 3, she understood these instructions as a request to come out of her house to sign some forms for the agency. Upon meeting RN 1 at the parking driveway, Patient 3 was surprised when RN 1 proceeded to administer the IV medication and checked her vital signs while she was standing next to RN 1’s vehicle. Patient 3 reported feeling traumatized by the experience of receiving an IV infusion outside her house where she was exposed to public view, expressing shock at the situation caused by the lack of privacy and concern over the lack of clear communication in her preferred language. During a phone interview, on 5/28/2026 at 9:57 a.m., with RN 1 stated and explained that she consistently communicates with Patient 3 in English and has never utilized interpreter services to facilitate communication in Spanish with Patient 3’s preferred language. When specifically asked whether she had confirmed Patient 3’s preferred language, RN 1 responded that she believed Patient 3 understands English. During a concurrent interview and record review, on 5/28/2026 at 1:40 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 3’s clinical record titled, High Tech Skilled Nursing Note, dated 3/22/2026. The ADM/DPCS stated there was no documentation in Patient 3’s clinical record to indicate Patient 3 was informed and gave consent that care and skilled services will be provided outside of the patient’s residence. The ADM/DPCS stated patients always have the right to be informed of the care and services to be performed or any changes to the care being provided and delivered in a language that the patient preferred and understood. The ADM/DPCS stated and acknowledged the findings. During a review of the agency’s policy and procedure (P&P) titled, Bill of Rights, revised November 2022, the P&P indicated each patient will be an active, informed participant in his/her plan of care. The patient Bill of Rights statement defines the right of the patient to be informed in advance about care to be furnished and of any changes in the care to be furnished, be advised in advance of the right to participate in planning the care or treatment and in planning changes in the care and treatment, and the right to have communication needs met. The organization shall provide verbal notice of the patient’s rights and responsibilities in the patient’s primary or preferred language and in a manner the individual understands.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) nursing staff failed to perform a completed pressure wound assessment for one of seven sampled patients (Patient 1), who had an open wound on the sacral region (a triangular bone at the base of the spine). This deficient practice can lead to inadequate treatment and longer healing times causing patient’s discomfort and/or pain. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 1’s start of care (SOC) date was 5/21/2026, with a diagnoses that included sepsis (the body’s extreme, life-threatening response to an infection), acute pyelonephritis (a sudden, severe bacterial infection of the kidneys), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a large, triangular bone situated at the base of your spine). During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and supporting an individual needs to meet their healthcare goals) for the certification period starting from 5/21/2026 to 7/19/2026, the POC included an order for the skilled nurse to visit daily until 5/27/2026 for skilled assessment and observation, vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse, and respiratory [breathing] rate) every visit, and checked medication status for patient’s response to medications, medication compliance and effectiveness. During a review of Patient 1’s clinical record titled, Comprehensive Adult Nursing Assessment (an in-depth, mandatory evaluation performed by a registered nurse (RN) at a patient’s residence to determine overall health, functional status, and home safety) dated 5/21/2026, the Comprehensive Adult Nursing Assessment indicated that under section M – Skin Conditions, Patient 1 has a stage 4 pressure ulcer in the sacral area, but the assessment did not include measuring the wound’s size (length, width, depth), undermining (tissue destruction under skin edges), and tunneling. During an interview and record review, on 5/28/2026 at 1:40 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 1’s Comprehensive Adult Nursing Assessment, dated 5/21/2026. The ADM/DPCS noted that the stage 4 pressure wound was not measured. The ADM/DPCS stated a complete assessment should include measurements of length, width, depth, undermining, and tunneling, as these are crucial for tracking healing and guiding treatment. During a review of the agency’s undated P&P titled, Assessment/Staging of Pressure Ulcers, the P&P indicated home care should use a risk assessment tool to determine risk and plan accordingly. In assessing the pressure ulcer, the following parameters should be addressed consistently: - Site, stage of ulcer, and size of ulcer (include length, width, and depth) - Presence of tunneling and undermining - Presence of necrotic tissue (slough or eschar) - Drainage amount, color, and odor - Granulation - Pain - Condition of surrounding tissue During a review of the agency’s policy and procedure (P&P) titled, Initial and Comprehensive Assessment, revised November 2022, the P&P indicated a comprehensive patient assessment will be completed by the registered nurse within five (5) calendar days of the patient’s start of care and shall verify the patient’s eligibility for the Medicare home health benefit, including homebound status. The assessment will be patient-specific and comprehensive to include the patient’s need for home care, rehabilitative care, social, and discharge planning needs. During the initial and comprehensive patient assessment, all baseline data to be used in measuring the patient’s progress towards goals and other relevant information will be documented in the patient’s clinical record, including at least the following information, if applicable: Specific, individualized patient needs and problems pertinent to the care being provided.”

“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 Home Health Agency (HHA, agency providing skilled nursing and other therapeutic services to a patient’s personal residence) failed to maintain an accurate, and current medication profiles for three of seven sampled patients (Patient 1, Patient 4, and Patient 5). This failure had the potential to place Patient 1, Patient 4, and Patient 5 at risk for medication errors and adverse drug reactions. a. b. During a review of Patient 4’s “Home Health Certification and Plan of Care,” (POC, a detailed, written document outlining the services and support an individual needs to meet their healthcare goals) for the certification period from 5/8/2026 to 7/6/2026, the POC indicated Patient 4 was admitted to the HHA on 5/8/2026 with a primary diagnosis of bilateral primary osteoarthritis (degenerative breakdown of joint cartilage). During a joint home visit on 5/27/2026 at 10:35 a.m. in Patient 4’s residence, with the Administrator/Director of Patient Care Services (ADM/DPCS), Patient 4 was observed lying in bed. During a review of Patient 4’s current medications on 5/27/2026 at 10:53 a.m. with the ADM/DPCS, the following medications were available at Patient 4’s residence but not listed in Patient 4’s medication profile or POC provided by the HHA: - Diclofenac (a medication used to relieve pain, swelling, and joint stiffness) topical gel, 1%. - Albuterol sulfate (a medication used to treat or prevent breathing difficulties) inhalation aerosol 90 micrograms (mcg, a unit of measurement). - Lidocaine (a topical medication used to relieve minor pain) patch, 4%. During a review of Patient 4’s current medications on 5/7/2026 at 10:53 a.m. with the ADM/DPCS, the following medications were not available in Patient 4’s residence but were listed in Patient 4’s medication profile and POC provided by the HHA: - Albuterol sulfate 0.083% inhalation solution. - Lidocaine 4% topical cream. c. During a review of Patient 5’s “Home Health Certification and Plan of Care,” (POC) for the certification period from 4/11/2026 to 6/9/2026, the POC indicated Patient 5 was admitted to the HHA on 4/11/2026 with a primary diagnosis of hemiplegia (a form of paralysis that affects one entire side of the body) following cerebral infarction (a medical emergency caused by disrupted blood flow to the brain). During a joint home visit on 5/27/2026 at 11:43 a.m. in Patient 5’s residence, with the ADM/DPCS, Patient 5 was observed lying in bed watching television. During a review of Patient 5’s current medications on 5/27/2026 at 11:55 a.m. with the ADM/DPCS, donepezil (a medication used to treat dementia symptoms) 5 milligrams (mg, a unit of measurement) was available at Patient 5’s residence but not listed in Patient 5’s medication profile or POC provided by the HHA. During an interview on 5/28/2026 at 10:30 a.m. with the ADM/DPCS, the ADM/DPCS stated medication reconciliation should be completed every visit by the visiting nurse. The ADM/DPCS stated completing medication reconciliation at each visit is important to ensure medications are being taken as prescribed and the medication profile remains current and accurate. Findings: a. During a review of Patient 1’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the Face Sheet indicated Patient 1’s start of care (SOC) date was 5/21/2026, with a diagnosis that includes sepsis (the body’s extreme, life-threatening response to an infection), acute pyelonephritis (a sudden, severe bacterial infection of the kidneys), and stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (a large, triangular bone situated at the base of your spine). During a review of Patient 1’s Home Health Certification and Plan of Care (POC, a detailed, written document outlining the services and supporting an individual needs to meet their healthcare goals) for the certification period starting from 5/21/2026 to 7/19/2026, the POC included an order for the skilled nurse to visit daily until 5/27/2026 for skilled assessment and observation, vital signs (measure the basic functions of the body that includes body temperature, blood pressure, pulse, and respiratory [breathing] rate) every visit, and checked medication status for patient’s response to medications, medication compliance and effectiveness. During a joint home visit, on 5/27/2026 at 12:00 p.m., at Patient 1’s residence with the registered nurse (RN 2), Patient 1 was observed laying in a hospital bed, awake, alert, and oriented x 3 (to person, place and time). During a review of Patient 1’s current medication with RN 2 during the visit, there was a bottle of Dakin’s solution (used as a topical antiseptic to clean acute and chronic wounds and prevent infections) 0.125% solution once daily found at the patient’s room. However, Patient 1’s current medication profile provided by the HHA indicated patient was not on this medication. During a concurrent interview with Patient 1, Patient 1 stated he has been using Dakin’s solution daily for the past several months to clean his wound as prescribed by the physician. During a review of the agency’s policy and procedure (P&P) titled, Medication Profile, revised November 2022, the P&P indicated 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.”