Southwest Medical Associates Home Health

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on employee record review, policy review, and interviews, the Home Health Agency (HHA) failed to ensure evidence of participation in any emergency preparedness (EP) in-services/drills and demonstrate staff knowledge of emergency procedures for seven of seven employees. The failure of the agency to not ensure employees’ knowledge related to emergency preparedness had the potential to result in a delay in emergency response and patient care in the event of a disaster or community emergency. Findings include: . During an interview on 05/06/2026 at 10:05 AM, the Clinical Operations Manager (COM) 13 stated that all agency policies and procedures, to include EP, were reviewed as part of the Governing Body Meeting on 09/15/2025. COM13 stated that all employees participated in a yearly “Business Continuity and Emergency Response Training “ online in October and that the test was scored to verify knowledge. COM13 was asked to provide documentation of the employees testing. COM13 provided a listing of the 138 employee names, date tested, and each employee’s score. The document verified a score of 100% for all 138 employees. COM13 was asked to provide a copy of the EP test. COM13 provided a form with one question that asked, “I confirm that I have completed the Emergency Preparedness Training for 2025. I understand the information provided to me and how to respond in the event of an emergency. A. True B. False.” COM13 stated the answer “A. True” gave a score of 100% and demonstrated employee knowledge and a “Certificate of Achievement” was available for each employee. COM13 stated the “Test” was actually the employee’s “affidavit” they had reviewed the EP program and not a test of knowledge of the EP training. Review of seven of seven EP personnel records revealed the following: 1.Home Health Aide (HHA) 6, on 12/02/2025 signed the affidavit that he/she reviewed the EP training and scored 100% by marking “A. True.” During an interview on 05/05/2026, at 8:30 AM, HHA6 stated he/she did not remember participation in training and never participated in an emergency preparedness drill. 2. Registered Nurse (RN) 4 at 10/21/2025 signed the affidavit that he/she reviewed the EP training and scored 100% by marking “A. True.” During an interview on 05/06/2026 at 9:30 AM, RN4 stated he/she did not remember participation in training but may have had a computer course. He/she stated did not remember a test and never participated in an emergency preparedness drill. 3. RN5 on 11/02/2025 signed the affidavit that he/she reviewed the EP training and scored 100% by marking “A. True.” During an interview on 05/06/2026 at 10:30 AM, RN5 stated he/she did not remember participating in training other than a computer course and did not remember taking a test. He/she stated they never participated in an emergency preparedness drill. 4. Speech Language Pathologist (SLP) 14 on 10/28/2025 signed the affidavit that he/she reviewed the EP training and scored 100% by marking “A. True.” During an interview on 05/05/2026 at 2:00 PM, SLP14 stated he/she did not remember participation in training although when asked if he/she had computer training he/she stated that they may have had it on a computer but had never participated in an emergency preparedness drill. 5. RN3 on 10/29/2025 signed the affidavit that he/she reviewed the EP training and scored 100% by marking “A. True.” During an interview on 05/05/2026 at 1:30 PM, RN3 stated he/she did not remember participation in training and had never participated in an emergency preparedness drill. 6. Occupational Therapist (OT) 9 on 10/31/2025 signed the affidavit that he/she reviewed the EP training and scored 100% by marking “A. True.” During an interview on 05/05/2026 at 12:15 PM, OT9 stated he/she remembered taking a computer course but did not remember taking a test. He/she stated that they had never participated in an emergency preparedness drill. 7. Physical Therapist (PT) 8 on 10/25/2025 signed the affidavit that he/she reviewed the EP training and scored 100% by marking “A. True.” During an interview on 05/06/2026 at 2:30 PM, PT8 stated he/she did not remember if he/she had training and never participated in a drill. Review of the facilities “Emergency Management Plan,” reviewed on 03/14/2025, failed to include the process of staff training and staff evaluation for emergency preparedness during actual disasters and/or drills. Review of the facilities “Business Continuity Plan,” reviewed on 03/14/2025, revealed “Create awareness and enhance the level of competencies of the business continuity planners/recovery team members in understanding the event notification process. Ensure department personnel are familiar with the department plan contents and their roles and responsibilities during an event.””

“EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: Based on review of the Emergency Preparedness Plan (EPP), emergency preparedness drill, and staff interviews, the facility failed to ensure that the EPP process included at least one testing exercise on an annual basis, which may be either one community-based full-scale exercise, if available, or an individual facility-based functional exercise. Every other year, opposite of the full-scale exercises, these providers may choose the testing exercise of their choice, which can include either another full-scale, individual facility-based, a mock disaster drill (using mock patients), tabletop exercise or workshop which included a facilitator and ensure that staff and patients were included. This failure has the potential to cause harm to 138 staff and 1000 current patients. Findings include: . Review of the facility’s “Emergency Management Plan,” last reviewed 03/14/2025, failed to include how testing will be conducted on an annual basis and including either one community-based full-size, if available, and an exercise of one additional drill within the two-year period. In addition, the plan did not detail how the patients and staff will be included in the drills. Review of the facilities “Business Continuity Plan,” reviewed on 03/14/2025, revealed “Create awareness and enhance the level of competencies of the business continuity planners/recovery team members in understanding the event notification process. Ensure department personnel are familiar with the department plan contents and their roles and responsibilities during an event.” Review of the emergency drill conducted by the facility titled, “Business Continuity Plan Exercise Report,” dated 06/10/2025, states the drill was a “tabletop drill resulting in the loss of Medline Vendor. Medline vendor is used for medical Supplies. If the vendor were unavailable to provide supplies the vendor would notify the Process lead directly, The Direct Patient Care team would determine inventory and share supplies between clinics as available, purchase them locally, or order them through Cardinal and or McKesson. This recovery strategy could be implemented immediately and be sustainable long term.” Participants that attended the drill consisted of only administrative and corporate staff; there was no evidence that the clinical staff were included in the tabletop exercise. The city of Las Vegas holds annual drills that all providers can attend called “Great Nevada Shakeout.” There was no indication that the facility had participated in the community wide drills. During an interview on 05/05/2026, at 8:30 AM, Home Health Aide (HHA) 6 stated he/she did not remember participation in training and never participated in an emergency preparedness drill. During an interview on 05/05/2026 at 1:30 PM, Registered Nurse (RN) 3 stated he/she did not remember participation in training and had never participated in an emergency preparedness drill. During an interview on 05/05/2026, at 12:15 PM, Occupational Therapist (OT) 9 stated he/she remembered taking a computer course but did not remember taking a test. He/she stated that they had never participated in an emergency preparedness drill. During an interview on 05/05/2026, at 2:00 PM, Speech Language Pathologist (SLP) 14 stated he/she did not remember participation in training although when asked if he/she had computer training he/she stated that they may have had it on a computer but had never participated in an emergency preparedness drill. During an interview 05/06/2026, at 9:30 AM, RN4 stated he/she did not remember participation in training but may have had a computer course but does not remember a test. and never participated in an emergency preparedness drill. During an interview on 05/06/2026, at 10:30 AM, RN5 stated he/she did not remember participating in training other than a computer course and did not remember taking a test. He/she stated they never participated in an emergency preparedness drill. During an interview on 05/06/2026, at 2:30 PM, Physical Therapist (PT) 8 stated he/she did not remember if he/she had training but never participated in a drill. An interview with the Administrator on 05/04/2026 at 3:45 PM confirmed that only the administrative and corporate staff attended the tabletop drill.”

“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, record review, policy review, and interview, the agency failed to ensure the medical record accurately reflected current medication orders in place for 3 of 7 sampled home visit patients (Patient (P) 15, P16, and P17) reviewed for medication reconciliation. This deficient practice had the potential to affect all 1,000 patients currently receiving services from the agency. Findings include: (For Submission Only) 1.Review of P15’s electronic medical record (EMR) revealed “physician’s orders” for the patient to receive visits from a Registered Nurse (RN) every week during the certification period beginning 03/25/2026 and revealed the following medication orders were no longer ordered by the physician but still on the patient medication list or plan of care (POC): Hydrocodone (Norco) 5-325 milligrams (mg) take one tablet by mouth one time daily. (pain medication) Observation during a homecare visit performed by the RN5 on 05/06/2026 at 10:30 AM revealed that P15’s “Medication List” found in P15’s EMR did not accurately reflect all the current medications and failed to remove the Hydrocodone 5-325. An interview on 05/06/2026 with P15 and RN5 at 10:30 AM, confirmed his/her current prescribed medication and that the above medication should have been removed on admission. 2. Review of P16’s EMR revealed “physician’s orders” for the patient to receive visits from an RN every week during the certification period beginning 04/02/2026. Observation during a homecare visit performed by the RN4 on 05/06/2026 at 2:15 PM revealed that 16’s “Medication List” found in P16’s EMR did not accurately reflect all the current medications: Potassium Chloride C120 Percent (%) 40 milliequivalent’s (mEq) three times daily. (used to replace low potassium levels), ordered prior to admission; Scopolamine patch, two times weekly. (Used to prevent motion sickness), ordered prior to admission; Levothyroxine was changed from 75 Micrograms (mcg) to 88 mcg on 04/01/26. (used to treat low thyroid function); Keppra XR 100 mg. Change from 500 mg to 100 mg three weeks prior to visit. (used for seizure disorders); Dulcolax one or two as needed (prn) (for constipation); and Imodium two mg prn (for diarrhea). An interview on 05/06/2026 with P16’s Caregiver (CG) 16 and RN4 at 2:40 PM, confirmed the current prescribed medications and the above across the counter medications were not included on the medication list or the current direction and dosage should have been changed on admission beginning 04/02/2026, and revealed the medication orders were currently being taken during the same time frame but were not included on the patients medication list or on the POC. 3. Review of P17’s EMR revealed “physician’s orders” for the patient to receive visits from a Speech Language Pathologist (SLP) 14 every week during the certification period beginning 04/16/2026. Observation during a homecare visit performed by SLP14 on 05/05/2026 at 2:00 PM revealed that 17’s “Medication List” found in P17’s EMR did not accurately reflect all the current medications as found on his/her medication bottles from the pharmacy: Eliquis 2.5 mg daily. (A medication to thin the blood), started on 03/20/2026; Diazepam 5mg on current order but no longer ordered. (a medication to treat anxiety), discontinued more than five years ago; Vitamin D3 2000 Mg (to preplace vitamin D deficiency), started on 02/22/2026; and Metoprolol 50mg) to treat high blood pressure), started on 02/11/2026. An interview on 05/05/2026 with P17 and SLP 14 at 2:30 PM confirmed his/her current prescribed medications and the above medications were not included on the list or should have been taken off on admission to the HHA beginning 04/16/2026. During an interview on 05/05/2026 at 1:30 PM, the Administrator confirmed the staff was not following the policy by not listing all medications including prescriptions and over the counter medications on the list. Review of the agency’s policy titled, “Medication Profile,” reviewed 03/14/2025, revealed “A medication reconciliation will be performed at the time of admission, when updates to the comprehensive assessments are preformed, when care is resumed after a patient has been on hold, and with the addition of new medications. This review will include all prescriptions and non-prescriptions. Initial list of medications prescriptions and non-prescriptions will be provided to the patient and /or family/care…” .”