Mlh Healthcare, 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 observation, 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 maintain an updated medication profile for three of eight sampled patients (Patient 2, 4, and 7) by failing to: 1. Update Patient 2’s medication profile to accurately reflect the doses of medications the patient was currently taking. 2. Update Patient 4’s medication profile to accurately reflect the medications and doses the patient was currently taking. 3. Update Patient 7’s medication profile to reflect a decrease in dosage of the pain medication Tramadol (medication for moderate and severe pain) from 100 milligram (mg) twice daily to 50 mg twice daily. These failures had the potential to place Patient 2, Patient 4, and Patient 7 at risk for medication errors, omissions, duplications, and adverse drug reactions, which could lead to hospitalization due to the absence of an accurate and up‑to‑date medication profile. (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 regulations for Comprehensive Assessment of patients to ensure the highest quality of care was being provided to patients certified to receive home health care and services.”

“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 Home Health Agency (HHA‑ an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure that three of eight sampled patients (Patient 2, 4, and 7) were provided copies of their individualized plan of care (a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them). This deficient practice caused Patients 2, 4, and 7 to be uninformed about services, goals, care schedules, medical instructions, and safety measures. A review of Patient 7’s Patient Profile indicated that the HHA admitted the Patient 7, an 87-year-old female, on 10/10/2025 with a diagnosis of idiopathic neuropathy (nerve damage where doctors cannot find a clear cause, often resulting in numbness, tingling, and pain in the feet and lower leg) and hypertension (high blood pressure). A review of Patient 7’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/6/2026to 10/4/2026. Patient 7 was to receive skilled nursing home visit once a week for 9 weeks. A concurrent interview and observation of Patient 7’s home health folder was done during a visit to Patient 7’s home on 8/19/2026 at 2:45 pm with Registered Nurse 1 (RN1). RN1 stated that the patient’s folder for keeping home health documentation and communication, did not have a copy her care plan. RN 1 stated that each patient should have a copy of their current care plan at home. During an interview on 8/20/2026 at 11:37 am with Director of Patient Services (DPCS), DPCS stated a copy of the care plan should be at each patients home to ensure consistent care amongst clinicians. DPCS stated that not having the care plan could lead to care issues. A review of Patient 4’s Patient Profile (face sheet- a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care (SOC) date of 6/4/2025, with diagnoses of neuropathy (nerve pain, most commonly in the hands and feet), essential hypertension (high blood pressure), arthropathy (any disease or disorder affecting the joints, such as arthritis), muscle spasm of back (a sudden involuntary contractions of a muscle that can cause sharp pain and tightness) and hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt such things as heart rate, body temperature and metabolism). A review of Patient 4’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 7/29/2026 to 9/26/2026. Patient 1 was to receive skilled nursing home visit once a week for 9 weeks. During a concurrent record review and interview on 8/19/2026 at 2:12pm, Patient 4’s Home Health Folder (a folder given to patients from the HHA that includes important information about the about the agency and the services they are providing) was reviewed with Administrator/Director of Nursing (ADM/DPCS) and did not have a copy of Patient 4’s Plan of Care. Patient 4 stated that he had not seen the folder for a long time, since he was admitted to the agency. Patient 4 stated that he does not have any other paperwork from the agency. During an interview on 8/20/2026, at 11:40am, the ADM/DPCS stated that the patients are supposed to have a copy of their Plan of Care in the home on order to have consistent care for patients in case a different nurse visit. The Plan of Care gives directions on how to care for the patient and what services need to be provided. The ADM/DPCS stated that the Plan of Care also serves as a reference for the patient and family, so they know what care they are supposed to be receiving. A review of the HHA’s policy titled “Care Planning Process”, dated November 2013, indicated at the time of the initial assessment, the clinician, along with other involved disciplines, will develop the patient plan of care based upon the patient’s identified needs and will review it with the patient and family/caregiver. The care planning decisions will be reflected in the specific services that will be provided and the associated actions planned and implemented to meet individualized patient problems and goals. A review of the HHA’s policy titled “Patient Education Process”, dated November 2013, indicated that Patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. During a review of Patient 2’s clinical record titled Patient Profile, undated, indicated Patient 2 had a start of care date of 6/19/2026 with primary diagnosis of type 2 diabetes (a disease where too much sugar is in the blood which can lead to serious health problems), hypertension (HTN-High blood pressure), unspecified dementia (a progressive state of decline in mental abilities) During a concurrent observation and interview on 8/19/2025 at 12:05 p.m. with Patient 2, Patient 2’s Home Health Patient folder was observed missing a Plan of Care (POC). Patient 2 stated she is not aware of what should be included in the folder and added that she did not know what a POC is used for. During an interview on 8/20/2026 at 11:35 a.m. with Administrator/Director of Patient Services (ADM/DPCS), the Administrator/Director of Patient Services (ADM/DPCS) explained during an interview that staff should include a copy of the Plan of Care (POC) in the Home Health Patient Folder. This ensures that both the patient and their caregiver understand the medications and care the patient receives. The ADM/DPCS emphasized that keeping a POC at the patient’s home helps maintain consistent care among visiting staff.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard 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 therapeutic services to a patient’s personal residence) failed to ensure Patient 1’s Physician Orders and Patient 3’s Discharge Instructions were authenticated, as two of eight sampled patients’ (Patients 1 and 3) clinical records were missing Physician, Registered Nurse, and/or Patient signatures. This deficiency could potentially result in incomplete, inaccurate, or delayed patient care due to missing authentication on Physician Orders and Discharge Instructions for Patient 1 and Patient 3, increasing the risk of miscommunication, improper implementation of care plans, medication or treatment errors, and compromised continuity of care. These failures have the potential to negatively affect patient safety, quality of care, and overall well‑being. During a review of Patient 1’s clinical record titled Patient Profile, undated, indicated Patient 1 had a start of care date of 10/20/2025 with primary diagnosis of hereditary and idiopathic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), and secondary diagnosis of hypertension (HTN-high blood pressure), and benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland) During a review of Patient 3’s clinical record titled Patient Profile, undated, indicated Patient 3 had a start of care date of 4/17/2026 with primary diagnosis of hereditary and idiopathic neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet), arthropathy(any disease or abnormality of the joints), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a concurrent interview and record review on 8/18/2026 at 3:20 p.m. with Medical Records (MR) personnel, Patient 1’s clinical record titled “Order/Telephone Order” dated, 4/14/2026, 5/25/2026 and 6/12/2026 were reviewed, MR confirmed the “Order/Telephone Order” were missing a physician signature. MR stated she last reviewed Patient 1’s clinical records on 7/6/2026 and overlooked the missing signatures on the “Order/Telephone Order” forms. The MR stated its important to have a physician During a concurrent interview and record review on 8/18/2026 at 3:20 p.m. with Medical Records (MR) personnel, Patient 3’s clinical record titled, Discharge Instructions, dated 4/17/2026-6/15/2026 was reviewed, MR confirmed Discharge Instructions was missing a staff and a patient signature. During a concurrent interview and record review on 8/20/2026 at , with ADM/DPCS, Patient 1’s “Order/Telephone Order” and Patient 3’s “Discharge Instructions” were reviewed. The ADM/DPCS confirmed Patient 1’s “Order/Telephone Order” and Patient 3’s “Discharge Instructions” were missing physician/staff and Patient signature. The ADM/DPCS added that Patient 3’s signature should have been verified the day of discharge to authenticate that Patient 3 agreed with his discharge. During a review of the facility’s policy and procedure titled “Verification of Physician Orders”, dated November 2013, the “Verification of Physician Orders” indicated, the original order will be delivered to the physician (or other authorized licensed independent practitioner) for his/her signature.Signed orders will be placed in the clinical record within 30 days of initiation of the order, unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed from the record. During a review of the facility’s Job Description for Medical Records Auditor, undated, indicated, the Medical Records Auditor performs a through medical record audit at all times on every intermittent home health agency patient to ensure accuracy, completeness and timelessness of all documentation required on all patient’s charts.”

“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, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to maintain an updated medication profile for three of eight sampled patients (Patient 2, 4, and 7) by failing to: 1. Update Patient 2’s medication profile to accurately reflect the doses of medications the patient was currently taking. 2. Update Patient 4’s medication profile to accurately reflect the medications and doses the patient was currently taking. 3. Update Patient 7’s medication profile to reflect a decrease in dosage of the pain medication Tramadol (medication for moderate and severe pain) from 100 milligram (mg) twice daily to 50 mg twice daily. These failures had the potential to place Patient 2, Patient 4, and Patient 7 at risk for medication errors, omissions, duplications, and adverse drug reactions, which could lead to hospitalization due to the absence of an accurate and up‑to‑date medication profile. During a review of Patient 2’s clinical record titled Patient Profile, undated, indicated Patient 2 had a start of care date of 6/19/2026 with primary diagnosis of type 2 diabetes (a disease where too much sugar is in the blood which can lead to serious health problems), hypertension (HTN-High blood pressure), unspecified dementia (a progressive state of decline in mental abilities) During a concurrent interview and record review on 8/19/2026, at 11:45 a.m., a medication reconciliation (is the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted with the Administrator/ Director of Nursing (ADM/DPCS) at Patient 2’s home. During the medication reconciliation, the following medication discrepancies (a difference or lack of agreement between two or more things that should match or be equal) were found… Amlodipine (medication to help lower blood pressure) 2.5 milligrams (mg- unit of measurement) 1 tablet by mouth daily.Patient’s 2 medication bottle indicated, 5mg, 1 tablet by mouth daily. Furosemide (medication to help lower blood pressure and to reduce fluid retention) 20mg 1 tablet by mouth daily.Patient’s 2 medication bottle indicated, 40mg 1 tablet by mouth daily. Patient 2’s medication pregabalin (medication to treat nerve pain) 50mg 1 tablet by mouth every night at bedtime.Patient 2 medication bottle indicated 25mg 1 tablet by mouth daily. Novolog (a rapid acting prescription insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) used to controlled high blood sugar in patients) 12 units subcutaneous (SQ) 3x dailyPatient 2 stated NovoLog is administered on a sliding scale (a method of giving short- or rapid-acting insulin doses that change based on a person’s current blood sugar level) of 8,10, 12 units. During an interview on 8/19/2026 at 12:30 p.m. with ADM/DPCS at Patient 2’s home, ADM/DPCS stated medication reconciliation needs to be done for Patient 2 to have a correct and up to date medication profile. ADM/DPCS stated a correct medication profile is important so the patient and patient care giver can be administering the correct medication dosage. The ADM/DPCS stated if Patient 2 takes too much or too little insulin it can cause a hyperglycemic (High levels of sugar in the blood) or hypoglycemic (low levels of sugar in the blood) emergency. During an interview on 8/20/2026 at 11:35 p.m. with ADM/DPCS, the ADM/DPCS stated the visiting nurse should be sitting down with patients to review their medication, going through every bottle at every home visit. The ADM/DPCS stated the importance of medication reconciliation is for the safety of the patient and to assure the patients are not over or under dosing. During a review of the facility’s policy and procedure titled “Medication Profile”, dated November 2013, the “Medication Profile”, indicated, Patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. During subsequent home visits, the medication profilewill be used as a care planning ad teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regime. During a review of the facility’s policy and procedure titled “Identification of Medication for Administration”, dated November 2013, the “Identification of Medication for Administration”, indicated, Prior to medication administration, the nurse will be familiar with the Patient’s medical history and will review present medication regimen…The nurse will review the medication label for name, additional patient identifier, drug dosage, and prescription. A review of Patient 7’s Patient Profile indicated that the HHA admitted Patient 7, an 87-year-old female, on 10/10/2025 with a diagnosis of idiopathic neuropathy (nerve damage where doctors cannot find a clear cause, often resulting in numbness, tingling, and pain in the feet and lower leg) and hypertension (high blood pressure). A review of Patient 7’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/6/2026 to 10/4/2026. Patient 7 was to receive skilled nursing home visit once a week for 9 weeks. A review of Patient 7’s medication profile indicated that patient was prescribed pain medication, Tramadol 50 mg, 2 tablets by mouth (for a total of 100mg) twice a day as needed for pain. During an observation on 8/19/2026 at 2:30 pm of Patient 7’s medication bottle of Tramadol, the bottle indicated Patient 7 to take 50 mg twice daily by mouth, as needed for pain. The fill date on the bottle was July 14, 2026. During an interview and concurrent review of Patient 7’s medication profile on 8/19/2026 at 2:30 pm, Patient 7 stated that her physician had changed her tramadol order from 100mg twice a day to 50 mg twice a day in July 2026. During an interview and concurrent record review of Patient 7’s medication profile on 8/19/2026 at 2:45 pm, Registered Nurse 1 (RN1) stated that the medication profile dosage of tramadol and the dose that the patient was taking did not match. RN1 stated that the dosage change that occurred in July 2026 was not updated on the medication profile and that the medication profile should be checked and any changes reported to the HHA with every visit. During an interview on 8/20/2026 at 11:34 am with Director of Patient Care Services (DCPS), DPCS stated that visiting nurses must review and document patient medications during every visit, reporting any changes to the office. DPCS stated this process was to ensure patient safety by ensuring patients take the correct dosage and avoid medication errors, such as overdosing or underdosing. A review of the facility’s policies and procedures titled, “Medication Profile,” dated November 2013, indicated, “patients receiving medications will have a current, accurate medication profile in the clinical record,” and, “medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.” b. A review of Patient 4’s Patient Profile (face sheet- a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care (SOC) date of 6/4/2025, with diagnoses of neuropathy (nerve pain, most commonly in the hands and feet), essential hypertension (high blood pressure), arthropathy (any disease or disorder affecting the joints, such as arthritis), muscle spasm of back (a sudden involuntary contractions of a muscle that can cause sharp pain and tightness) and hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt such things as heart rate, body temperature and metabolism). A review of Patient 4’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 7/29/2026 to 9/26/2026. Patient 1 was to receive skilled nursing home visit once a week for 9 weeks. Patient 4’s POC indicated that the patient will continue to receive all medications prescribed with caregiver assist without adverse effects and drug interactions in 9 weeks certification period. If not completely attained, will continue giving instructions and monitoring until end of certification period. On 8/19/2026, at 1:21pm, a medication reconciliation (is the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted with the Administrator/ Director of Nursing (ADM/DPCS) at Patient 4’s home. A review of Patient 4’s medication profile for episode period 7/29/2026 to 9/26/2026 indicated the following orders with discrepancies… Norco (a narcotic- a strong pain medication) 10/325 milligrams (mg-unit of measurement) 1 tablet (tab) by mouth twice a day as needed. Patient 4’s. medication bottle with a fill date of 8/12/2026 indicated Norco 10/325 mg, take 1 tablet by mouth 5 times a day for pain. 2. Tizanidine (medication to treat muscle spasms) 2mg. 1 tab by mouth twice a day as needed. Patient 4’s medication bottle with a fill date of 8/5/2026, indicated Tizanidine 4mg. take 1 tab nightly 3. Levothyroxine 50 micrograms (mcg-unit of measurement) 1 tab by mouth daily. Patient 4’s medication bottle 8/5/2026, indicated Levothyroxine 137mcg, 1 tab daily. The following medications were listed on Patient 4’s medication profile, but were not found in the patient’s home… HCTZ (hydrochlorothiazide-used to treat high blood pressure and fluid retention)12.5 mg, take one tab by mouth daily.Senokot (medication to trat constipation) 8.6 mg, 1 tab by mouth daily as needed (PRN).Valsartan (high blood pressure medication) 40mg 1 tab by mouth daily.Amlodipine (high blood pressure medication) 10 mg. 1 tablet by mouth daily.Diclofenac topical gel (treats pain, swelling and stiff joints) 1%- apply to affected area 1-3 times daily as needed.Lidocaine patch (a topical medication that numbs nerves in a specific area to provide temporary relief from localized muscle, joint or nerve pain.Patient 4 was taking the following medications, but they were not listed on his medication profile. Colchicine (medication to treat gout-a painful type of inflammatory arthritis caused by build up uric acid around the joints) 0.6 mg tab. Take 2 tabs by mouth as needed. May repeat 1 tab, one hour later. Max 3 tabs a day. Medication fill date 8/5/26.Magnesium Citrate (supplement to treat constipation) 250 mg. (over the counter medication).Anoro Ellipta (inhaler used to treat chronic obstructive pulmonary disease) 1 puff daily. Filled 5/21/2026.During an interview on 8/20/2026, at 11:40am, the ADM/DPCS stated that the visiting nurse should be reviewing all medications at each visit. The visiting nurse should be comparing the patient’s bottle to the medication list. The ADM/DPCS stated that the medications that the patient is taking need to match the medication profile to monitor the safety and effectiveness of the medications. The HHA need to make sure that they are not overdosing or underdosing the medication. Findings: A. During a review of Patient 2’s clinical record titled “Patient Profile”, undated, the record indicated that Patient 2 had a start of care date of 6/19/2026 with primary diagnoses of type 2 diabetes (a disease where too much sugar is in the blood which can lead to serious health problems), hypertension (HTN-High blood pressure), unspecified dementia (a progressive state of decline in mental abilities). During a concurrent interview and record review on 8/19/2026, at 11:45 a.m. with the Administrator/ Director of Nursing (ADM/DPCS), at Patient 2’s residence, Patient 2’.a medication reconciliation (is the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted During the medication reconciliation, the following medication discrepancies (a difference or lack of agreement between two or more things that should match or be equal) were found… Amlodipine (medication to help lower blood pressure) 2.5 milligrams (mg- unit of measurement) 1 tablet by mouth daily.Patient’s 2 medication bottle indicated, 5mg, 1 tablet by mouth daily. Furosemide (medication to help lower blood pressure and to reduce fluid retention) 20mg 1 tablet by mouth daily.Patient’s 2 medication bottle indicated, 40mg 1 tablet by mouth daily. Patient 2’s medication pregabalin (medication to treat nerve pain) 50mg 1 tablet by mouth every night at bedtime.Patient 2 medication bottle indicated 25mg 1 tablet by mouth daily. Novolog (a rapid acting prescription insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) used to controlled high blood sugar in patients) 12 units subcutaneous (SQ) 3x dailyPatient 2 stated NovoLog is administered on a sliding scale (a method of giving short- or rapid-acting insulin doses that change based on a person’s current blood sugar level) of 8,10, 12 units. During an interview on 8/19/2026 at 12:30 p.m. with ADM/DPCS at Patient 2’s home, ADM/DPCS stated medication reconciliation needs to be done for Patient 2 to have a correct and up to date medication profile. ADM/DPCS stated a correct medication profile is important so the patient and patient care giver can be administering the correct medication dosage. The ADM/DPCS stated if Patient 2 takes too much or too little insulin it can cause a hyperglycemic (High levels of sugar in the blood) or hypoglycemic (low levels of sugar in the blood) emergency. During an interview on 8/20/2026 at 11:35 p.m. with ADM/DPCS, the ADM/DPCS stated the visiting nurse should be sitting down with patients to review their medication, going through every bottle at every home visit. The ADM/DPCS stated the importance of medication reconciliation is for the safety of the patient and to assure the patients are not over or under dosing. B. A review of Patient 4’s Patient Profile (face sheet- a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care (SOC) date of 6/4/2025, with diagnoses of neuropathy (nerve pain, most commonly in the hands and feet), essential hypertension (high blood pressure), arthropathy (any disease or disorder affecting the joints, such as arthritis), muscle spasm of back (a sudden involuntary contractions of a muscle that can cause sharp pain and tightness) and hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt such things as heart rate, body temperature and metabolism). A review of Patient 4’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 7/29/2026 to 9/26/2026. Patient 1 was to receive skilled nursing home visit once a week for 9 weeks. Patient 4’s POC indicated that the patient will continue to receive all medications prescribed with caregiver assist without adverse effects and drug interactions in 9 weeks certification period. If not completely attained, will continue giving instructions and monitoring until end of certification period. On 8/19/2026, at 1:21pm, a medication reconciliation (is the process of comparing a patient’s medication orders to all the medications that the patient has been taking) was conducted with the Administrator/ Director of Nursing (ADM/DPCS) at Patient 4’s home. A review of Patient 4’s medication profile for episode period 7/29/2026 to 9/26/2026 indicated the following orders with discrepancies… Norco (a narcotic- a strong pain medication) 10/325 milligrams (mg-unit of measurement) 1 tablet (tab) by mouth twice a day as needed. Patient 4’s. medication bottle with a fill date of 8/12/2026 indicated Norco 10/325 mg, take 1 tablet by mouth 5 times a day for pain. 2. Tizanidine (medication to treat muscle spasms) 2mg. 1 tab by mouth twice a day as needed. Patient 4’s medication bottle with a fill date of 8/5/2026, indicated Tizanidine 4mg. take 1 tab nightly 3. Levothyroxine 50 micrograms (mcg-unit of measurement) 1 tab by mouth daily. Patient 4’s medication bottle 8/5/2026, indicated Levothyroxine 137mcg, 1 tab daily. The following medications were listed on Patient 4’s medication profile, but were not found in the patient’s home… HCTZ (hydrochlorothiazide-used to treat high blood pressure and fluid retention)12.5 mg, take one tab by mouth daily.Senokot (medication to trat constipation) 8.6 mg, 1 tab by mouth daily as needed (PRN).Valsartan (high blood pressure medication) 40mg 1 tab by mouth daily.Amlodipine (high blood pressure medication) 10 mg. 1 tablet by mouth daily.Diclofenac topical gel (treats pain, swelling and stiff joints) 1%- apply to affected area 1-3 times daily as needed.Lidocaine patch (a topical medication that numbs nerves in a specific area to provide temporary relief from localized muscle, joint or nerve pain.Patient 4 was taking the following medications, but they were not listed on his medication profile. Colchicine (medication to treat gout-a painful type of inflammatory arthritis caused by build up uric acid around the joints) 0.6 mg tab. Take 2 tabs by mouth as needed. May repeat 1 tab, one hour later. Max 3 tabs a day. Medication fill date 8/5/26.Magnesium Citrate (supplement to treat constipation) 250 mg. (over the counter medication).Anoro Ellipta (inhaler used to treat chronic obstructive pulmonary disease) 1 puff daily. Filled 5/21/2026.During an interview on 8/20/2026, at 11:40am, the ADM/DPCS stated that the visiting nurse should be reviewing all medications at each visit. The visiting nurse should be comparing the patient’s bottle to the medication list. The ADM/DPCS stated that the medications that the patient is taking need to match the medication profile to monitor the safety and effectiveness of the medications. The HHA need to make sure that they are not overdosing or underdosing the medication. C. A review of Patient 7’s Patient Profile indicated that the HHA admitted Patient 7, an 87-year-old female, on 10/10/2025 with a diagnosis of idiopathic neuropathy (nerve damage where doctors cannot find a clear cause, often resulting in numbness, tingling, and pain in the feet and lower leg) and hypertension (high blood pressure). A review of Patient 7’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 8/6/2026 to 10/4/2026. Patient 7 was to receive skilled nursing home visit once a week for 9 weeks. A review of Patient 7’s medication profile indicated that patient was prescribed pain medication, Tramadol 50 mg, 2 tablets by mouth (for a total of 100mg) twice a day as needed for pain. During an observation on 8/19/2026 at 2:30 pm of Patient 7’s medication bottle of Tramadol, the bottle indicated Patient 7 to take 50 mg twice daily by mouth, as needed for pain. The fill date on the bottle was July 14, 2026. During an interview and concurrent review of Patient 7’s medication profile on 8/19/2026 at 2:30 pm, Patient 7 stated that her physician had changed her tramadol order from 100mg twice a day to 50 mg twice a day in July 2026. During an interview and concurrent record review of Patient 7’s medication profile on 8/19/2026 at 2:45 pm, Registered Nurse 1 (RN1) stated that the medication profile dosage of tramadol and the dose that the patient was taking did not match. RN1 stated that the dosage change that occurred in July 2026 was not updated on the medication profile and that the medication profile should be checked and any changes reported to the HHA with every visit. During an interview on 8/20/2026 at 11:34 am with Director of Patient Care Services (DCPS), DPCS stated that visiting nurses must review and document patient medications during every visit, reporting any changes to the office. DPCS stated this process was to ensure patient safety by ensuring patients take the correct dosage and avoid medication errors, such as overdosing or underdosing. During a review of the facility’s policy and procedure titled “Medication Profile”, dated November 2013, indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications... 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 regime. During a review of the facility’s policy and procedure titled “Identification of Medication for Administration”, dated November 2013, indicated... Prior to medication administration, the nurse will be familiar with the Patient’s medical history and will review present medication regimen…The nurse will review the medication label for name, additional patient identifier, drug dosage, and prescription.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA‑ an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to ensure that one of eight sampled patients (Patient 4) was provided a copy of their Medication Profile (an organized, up‑to‑date record of all the medicines a person takes). This deficient practice placed Patient 4’s health at risk for potentially misunderstanding medication instructions and increasing the likelihood of medication omissions, duplications, dosing errors, or adverse drug events. A review of Patient 4’s Patient Profile (face sheet- a document of a patient’s personal information such as diagnoses, date of birth, and address) indicated a start of care (SOC) date of 6/4/2025, with diagnoses of neuropathy (nerve pain, most commonly in the hands and feet), essential hypertension (high blood pressure), arthropathy (any disease or disorder affecting the joints, such as arthritis), muscle spasm of back (a sudden involuntary contractions of a muscle that can cause sharp pain and tightness) and hypothyroidism (condition in which the thyroid gland does not produce enough thyroid hormone which can disrupt such things as heart rate, body temperature and metabolism). A review of Patient 4’s Plan of Care (POC: a personalized document that outlines a patient’s health conditions, specific goals, and the medical or supportive services required to address them) indicated a certification period (home health certification period is a 60-day block of time authorized for a patient’s skilled care plan) from 7/29/2026 to 9/26/2026. Patient 1 was to receive skilled nursing home visit once a week for 9 weeks. During a concurrent record review and interview on 8/19/2026 at 2:12pm, Patient 4’s Home Health Folder (a folder given to patients from the HHA that includes important information about the about the agency and the services they are providing) was reviewed with Administrator/Director of Patient Care Services (ADM/DPCS) and Patient 4. Patient 4 did not have a copy of his Medication Profile. Patient 4 stated that he does not have any other paperwork from the agency. A review of the HHA’s policy titled “Medication Profile” , dated November 2013, indicated that the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, route, frequency and a diagnosis, condition, or indication for use for each medication ordered… Each patient and/or family/caregiver will receive appropriate written material for specific medications he/she is receiving. The material will contain information on actions of the medication, potential side effects, contraindications, and any special instructions when taking the specific medication.”

“Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This Element is not met as evidenced by: Based on record review and interview, the Home Health Agency (HHA) failed to ensure five of five employees were qualified to provide home health services (Administrator/Director of Patient Care Services (ADM/DPCS), Registered Nurse 1 (RN 1), Registered Nurse 2 (RN 2), Licensed Vocational Nurse 3 (LVN 3), and Physical Therapist 1 (PT 1)). 1. RN 2 did not have a background check (a process that verifies an individual’s identity and information such as criminal records, employment history, and arrest records). 2. LVN 3 did not have a background check, had no current Performance Evaluation (PE‑ a process used by organizations to assess how well employees are performing in their respective roles), and had an incorrect signed job description (a document that details essential job functions, responsibilities, qualifications, and expectations for a specific role within an organization). 3. PT 1 did not have a background check. 4. ADM/DPCS did not have an updated Tuberculosis test (TB‑ a test that checks if the body has been infected with the TB bacteria), did not have a current Annual Physical Exam (an overall body and health assessment performed by a licensed individual to ensure the employee can safely perform their duties), had no current PE, and their initial skills assessment (an evaluation done to check an employee’s abilities and knowledge at time of hire) was not signed by a Registered Nurse verifying completion. 5. RN 1 did not have an updated TB test or Annual Physical Exam, had no current PE, and their initial skills assessment was incomplete. These deficient practices had the potential to result in substandard care and services that could affect patient safety and well‑being. During a concurrent interview and record view on 8/20/2026 at 11:50 am with Administrator/ Director of Patient Care Services (ADM/DCPS), Registered Nurse 1’s (RN 1) employee file was reviewed. RN 1’s employee file was reviewed and the following was found: 1. Physical Exam on file was dated 5/22/2023 2. Tuberculosis (TB- contagious infection that most commonly attacks the lungs) test (a screening for TB) and clearance from a physician was dated 9/1/2021. 3. Initial skills assessment (an evaluation done to check an employee’s abilities and knowledge at the time of hire) was missing all completion dates and RN 1 did not sign the form to verify completion and review of the assessment done. 4. One Performance Evaluation (PE -a process used by organizations to assess how well employees are performing in their roles) was on file with blank dates. ADM/DPCS stated that RN1 was hired in January 2021. ADM/DPCS stated RN 1 should have annual physical exams and TB screenings on file at the HHA. ADM/DCPS stated that the initial skills assessment should have been signed by RN1 verifying completion and review with RN 1. ADM/DPCS stated that PE’s should have been done and filed on RN 1’s employee file every year. ADM/DPCS stated that any dates on forms should be filled out and not left blank. During a concurrent interview and record review on 8/20/2026 at 11:50 am with ADM/DPCS, ADM/DPCS employee file was reviewed. ADM/DPCS employee file was reviewed and the following was found: 1. Physical exam on file was 12/10/2020. 2. TB test on file was an chest Xray dated 12/1/2017, and was not signed by a physician. 3. Initial Skills Assessment skills on file was dated 12/1/2017 and the signatures validating completion of assessment by another registered nurse were blank 4. Performance Evaluation on file was dated 12/1/2017 and was not signed by the reviewer performing the evaluation. ADM/DPCS stated her date of hire was 12/1/2017. ADM/DPCS stated when a chest xray was done for TB testing, it should be redone in and submitted in 5 years. ADM/DPCS stated that the Director of Patient Care Services Designee (DPCSD) was responsible for performing her competency assessment and performance evaluation. During an interview on 8/20/2026 at 11:55 am with ADM/DPCS, ADM/DPCS stated all employees should submit proof of physical exam annually. ADM/DPCS stated that tuberculosis testing was required every year, unless a chest was done then it’s required every 5 years. ADM/DPCS stated the purpose of health screening and TB screenings requirements was to ensure the health and safety of both patients and staff, and that it was part of infection control and prevention to prevent patients from being exposed to illnesses, such as TB. During an interview with ADM/DPCS on 8/20/2026 at 11:57 am with ADM/DPCS, ADM/DPCS stated that all employees should have a PE annually, including a skill competency check to ensure that the employees are knowledgeable in the skills used to treat patients. ADM/DPCS stated that this process was done for the overall safety of patients, to ensure that the staff taking care of them was competent. ADM/DPCS stated that for her evaluation and skills check that another Registered Nurse would have to evaluate her and sign off on A review of the facility’s undated policies and procedures titled, “Personnel Records,” indicated, ongoing employment personnel files should contain performance appraisals, competency reviews, physicals, and TB screenings. A review of the facility’s undated policies and procedures titled, “Competency Evaluation of Home Care Staff,” indicated the agency will, “implement an objective measurable competence assessment program.” The policy further indicated, “the competency evaluations will be completed by individuals who have the knowledge and skills to assess competency,” and “all competencies will be documented.” The policy also indicated, “annual performance reviews will address competencies in areas of essential function.” A review of the facility’s undated policies and procedures titled, “Performance Evaluations,” indicated, “a competency-based performance evaluation will be conducted for all employees after one year of hire and at least annually thereafter.” B. A review of Licensed Vocational Nurse 3’s (LVN 3) employee file (an official collection of documents tracking an individual’s employment history, performance, and basic details from hiring to offboarding which include documents such as job application, signed employment contracts, job descriptions and performance reviews) indicated that they were hired on 2/1/2022. LVN 3’s employee file did not have the following… a background checkcurrent performance evaluation (PE) did not have a correct, signed job description. LVN had a signed job description dated 2/1/2022 for a RN (a licensed healthcare professional who provides and coordinates patient care, records medical histories, administer treatments, and educates patients and the public on health conditions. RNs have a broader scope of practice, complete longer education programs compared to an LVN) position instead of a LVN (an entry-level healthcare professional who provides basic medical and bedside care under the supervision of a registered nurse [RN] or physician).A review LVN 3’s Board of Vocational Nursing and Psychiatric Technicians Licensing Details indicated that LVN 3 has a current LVN license that expires on 10/30/2027. During an interview on 8/20/2026 at 11:40 am, the ADMN/DPCS stated the following: The purpose of a background check is to see if there are any limitations or restrictions on an employee’s license, such as felonies or sexual offences, to ensure the safety of their patients. The ADMN/DPCS stated that she is supposed to run a background check at time of hire. PEs are done annually to make sure their nursing skills are up to date for safety of patients.Job description should match employee license. ADM/DPCS confirmed that LVN 3 had the wrong job description and that he was an LVN not an RN. ADM/ DPCS stated that the job descriptions needed to match the job role, because it was job specific and it specified what skills they are allowed to do and what is expected from them.During a review of the facility’s policy and procedure (P&P) titled “Home Health Agency Personnel Records” (undated), indicated Personnel files will be established and maintained for all personnel… Personnel Records:Pre-employment information:Criminal history and background checks as required by law.Signed job descriptionsPerformance appraisalsCompetency reviewsPhysical, if requiredTB screening (2-step Mantoux), chest x-ray or evidence of treatment as indicatedStaff members contracted to the agency through another organization will have the following information available to review in the contracting agency’s personnel record. Criminal history recordA review of HHA’s P&P titled “Competency Evaluation for Home Health Staff” (Undated), indicated the following... The agency will implement an objective measurable competence assessment program. The assessment will verify and focus on the individual staff knowledge and skill appropriate to assigned responsibilities, communication skills, and the ability to respond to client needs within their scope of responsibility. The competency evaluations will be completed by individuals who have the knowledge and skills to assess competency. Supervisory and management staff are responsible for the competence of any care that they provide. All competencies will be documented A review of the HHA’s P&P titled “Performance Evaluations” (undated), indicated a competency-based performance evaluation will be conducted for all employees after one (1) year of employment and at least annually thereafter. The completed performance evaluation form will be reviewed and signed by the person performing the evaluation and the employee. During a review of Registered Nurse 2’s Employee File, undated, RN 2’s Employee File was missing an employee background check. During a concurrent interview and record review on 8/20/2026 at 11:35 p.m. with Administrator/Director of Patient Services (ADM/DPCS) RN 2’s Employee Profile, undated was reviewed. The ADM/DPCS confirmed that RN 2’s Employee Profile lacked an employee background check. The ADM/DPCS explained that staff must conduct an employee background check to determine if any restrictions exist on an employee’s license. The ADM/DPCS also clarified that the Medical Director (MR) assembles the employee files, and the ADM/DPCS verifies the completeness of these files. During a review of the facility’s policy and procedure (p&p) titled Home Helath Agency Personnel Records, undated, indicated, Personnel files will be established and maintained for all personnel… Personnel Records:Pre-employment information:Criminal history and background checks as required by law.”