Theracare Home Health

“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 interview and record review the agency failed to participate in a full scale, community-based exercise at least every other year to test its emergency preparedness and response plan in 2 (2024 and 2025) out of the 3 years reviewed, in that the agency performed facility-based fire drills only and did not involve patients in the drills. This failure could place patients, employees, and the agency at risk of not being prepared to respond to any disaster. Findings included: Review of the document titled, “Evaluation of Emergency Preparedness Implementation,” dated 1/17/24, revealed the agency conducted a “Fire Drill”. The “Narrative of Events” stated the following: “Explained to staff need to evacuate the build and gather meeting place, mailboxes to the left of office.” The evaluation of the drill read: “Performed evaluation in a proficient manner and according to policy.” No other drills or activation of the emergency response plan in 2024 were located. Review of the document titled, “Evaluation of Emergency Preparedness Implementation,” dated 3/28/25, revealed the agency conducted a “Fire Drill”. The “Narrative of Events” stated the following: “Explained to staff need to evacuate the build and gather meeting place, mailboxes to the left of office.” The evaluation of the drill read: “Performed evaluation in a proficient manner and according to policy.” Review of the document titled, “Evaluation of Emergency Preparedness Implementation,” dated 12/8/25, revealed the agency conducted a “Fire Drill”. The “Narrative of Events” stated the following: “Explained to staff need to evacuate the build and gather meeting place, mailboxes to the left of office.” The evaluation of the drill read: “Performed evaluation in a proficient manner and according to policy.” No additional drills or activation of the emergency response plan in 2025 were located. Review of the document titled, “Emergency Preparedness Plan and Procedure Checklist,” signed and dated 12/6/24, revealed a statement that read in part, “Fire drills will be conducted at least annually. Staff will be responsible for knowing where fire extinguishers and exits are located. Conduct exercises to test the emergency plan at least annually. Participate in a full-scale exercise every two (2) years, that is community-based. If a community-based exercise is not accessible, a facility-based functional exercise will be conducted every two (2) years. Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise is conducted, that may include, but is not limited to the following: A second full-scale exercise that is community-based or individual facility-based functional exercise, or A mock disaster drill, or A tabletop exercise or workshop that includes 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. Note: If a community-based exercise is not accessible, an individual, facility-based exercise will be conducted. The Agency will document efforts to identify a full-scale community-based exercise if they did not participate in one (i.e. date, personnel, and agencies contacted and the reasons for the inability to participate in a community-based exercise).” Review of the document titled, “Emergency Preparedness Plan and Procedure Checklist,” signed and dated 12/1/25, revealed a statement that read in part, “Fire drills will be conducted at least annually. Staff will be responsible for knowing where fire extinguishers and exits are located. Conduct exercises to test the emergency plan at least annually. Participate in a full-scale exercise every two (2) years, that is community-based. If a community-based exercise is not accessible, a facility-based functional exercise will be conducted every two (2) years. Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise is conducted, that may include, but is not limited to the following: A second full-scale exercise that is community-based or individual facility-based functional exercise, or A mock disaster drill, or A tabletop exercise or workshop that includes 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. Note: If a community-based exercise is not accessible, an individual, facility-based exercise will be conducted. The Agency will document efforts to identify a full-scale community-based exercise if they did not participate in one (i.e. date, personnel, and agencies contacted and the reasons for the inability to participate in a community-based exercise).” In an interview with the Administrator at 11:15 AM on 3/5/26, she stated that she was Disaster Coordinator for 2026 and going forward would be responsible for all drills and activations. Surveyor 2 informed the Administrator that their policy stated that if they were unable to find a full-scale community-based exercise then a facility-based drill would suffice, but the attempts to find a community-based drill would be documented. Surveyor 2 asked if they had attempted this and the Administrator was not sure but stated she would look for documentation of this. The Administrator was unable to find this. Surveyor 2 asked if the emergency activation system had been activated in 2025 and 2024. The Administrator stated that she was not sure since she was a new administrator, but going forward, she would make sure any activation of the emergency response was documented. Surveyor 2 asked why it was important to test the EP plan using full- scale, community-based exercises, at least every other year. The Administrator stated it was important “because we need to know what is working and what needs to be improved. Ultimately, we need to make sure that we can function well in an emergency and keep our patients safe.” The Surveyor asked how not testing the emergency response plan could affect patient care. The Administrator replied that the emergency response plan is made to keep clients safe during an emergency and testing it with patients is important to help keep them safe. In an interview with Operations Specialist C at 11:30 AM on 3/5/26, the surveyor showed her where she had signed as “Disaster Coordinator” for 2024 and 2025. She stated that she thought she was the alternate disaster coordinator. She stated that the Disaster Coordinator for 2025 and 2024 was the old administrator. The old administrator for 2025 and 2024 no longer worked at the agency at the time of the survey and was not available for interview. Surveyor 2 asked why Operations Specialist C had signed as the Disaster Coordinator for 2025 and 2024. Operations Specialist C said she probably had signed because the administrator had not been there during those drills. Surveyor 2 noted that there was no documentation of activation of the emergency response plan and asked if the emergency response system had been activated during 2025 or 2024. Operations Specialist C stated that she did not think so, since it was not in the binder. Surveyor 2 Surveyor asked if Operations Specialist C was responsible for running the drills in 2024 and 2025 and she stated that she was. Surveyor 2 asked what these drills consisted of. She stated she would call out “Fire!” at an unexpected time and all office staff would be expected to evacuate to the assigned location, which was the mailboxes in the parking lot. Surveyor 2 asked if field staff were included in these drills. Operations Specialist C stated, “Sometimes we do it in conjunction with our case conference, so we have field staff here, but not if they are out in the field.” Surveyor 2 asked if there were any other community agencies involved in the fire drills. Operations Specialist C stated, “We have participated in some full-scale drills at the [community center] in the past, but I think for the last 2 years the fire drills were just in the office and we didn’t involve the fire department.” Surveyor 2 asked if clients were included in these drills? Operations Specialist C stated, “No. Fire drills are done in the office. We do an unplanned announcement of fire and do a practice evacuation.” Surveyor 2 asked if patients were involved in the drills? Operations Specialist C stated that they were not. Surveyor 2 asked if the drill included an activation of the call tree to clients. Operations Specialist C stated, “Typically not for a fire drill, no.” Review of the agency’s policy titled, “Emergency Preparedness and Response Plan,” dated 9/15/24, revealed a document that read in part, “The Agency will conduct exercises to test the emergency plan at least annually. The Agency will: 1) Participate in a full-scale community-based exercise every two years. If participation in a community-based exercise is not possible, a facility-based functional exercise will be conducted every two years. The Agency will document efforts to identify a full-scale community-based exercise if they did not participate in one (i.e., date, personnel, and agencies contacted and the reasons for the inability to participate in a community-based exercise). If the Agency experiences an actual natural or man-made emergency that requires activation of the emergency plan, the Agency is exempt from engaging in its next required full-scale community-based or facility based functional exercise for one year following the onset of the emergency event. 2) Conduct an additional exercise every two years, opposite the year the full-scale community-based or facility-based functional exercise is conducted, that may include, but is not limited to the following: a) A second full-scale community-based or facility-based functional exercise, or b) A mock disaster drill, or c) A tabletop exercise or workshop that includes 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.””

“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, and interview, the agency failed to maintain a current medication list for 2 of 3 patients for which home visits occurred (Patient 1 and Patient 3). This failure placed patients at risk of undetectable adverse events due to medications. Findings included: Record review of document titled “Patient Medication Report (Patient 1),” dated for the certification period of 2/15/26-4/15/26, revealed that the current list of medications for Patient 1 include the following: Anastrozole (Metastatic Breast Cancer) 1 mg oral tablet, Ascorbic Acid (Supplement) 500 mg oral tablet, Aspirin (Anticoagulant) 81 mg oral tablet, Biotin (Supplement) 5 mg oral tablet, Calcium 600 mg + D3 600 mg oral tablet, Centrum Silver (Supplement) 0.4 mg oral tablet, Cetirizine (Allergies) 10 mg oral tablet, Cholecalciferol (Supplement) 50 mcg oral tablet, Cinnamon (Supplement) 500 mg oral tablet, Cyanocobalamin (Supplement) 1000 mcg oral tablet, Cyclobenzaprine 5 mg oral tablet, Diphenhydramine (Allergies) 25 mg oral tablet, Gabapentin (Neuropathy) 100 mg oral tablet, Hydrocortisone (Skin Irritation) 1% Topical cream daily, Ipratropium Bromide (Bronchodilator) 21 mcg Nasal Spray daily, Irbesartan 300 mg-Hydrochlorothiazide 12.5 (Hypertension) mg oral tablet, Ketoconazole 2% Shampoo (Antifungal) Topical, Levothyroxine (Hypothryroidism) 112 mcg oral tablet, Liothyronine (Hypothyroidism) 5 mcg oral tablet, Magnesium (Supplement) 200 mg oral tablet, Meloxicam (NSAIDs) 7.5 mg oral tablet, Metoprolol Tartrate (Hypertension) 25 mg oral tablet, Nitrofurantoin (Antibiotic) 100 mg oral tablet, Probiotic (Probiotic/Gastro Supplement) 10 Billion Cell Capsule oral, Rezdiffra (NASH) 60 mg oral tablet, Rosuvastatin (Hyperlipidemia) 5 mg oral tablet, Tizanidine (Muscle Relaxant) 4 mg oral capsule. Record review of document titled “Patient Medication Report (Patient 3),” dated for the certification period of 1/9/2026-3/9/26, revealed that the current list of medications for Patient 3 included the following: Azo Cranberry (UTIs) 250 mg oral tablet, Baclofen (Muscle Relaxant) 10 mg oral tablet, Calcium 600 mg + D3 600 mg (Supplements) oral tablet, Florajen Acidophilus (Probiotic) 20 Billion Cell oral capsule, Lasix (Diuretic) 40 mg oral tablet, Lyrica (Neuropathic pain) 75 mg oral capsule, Magnesium (Supplement) 250 mg oral tablet, Methocarbamol Muscle Relaxant) 1000 mg oral tablet, Multiple Vitamins (Supplements) oral tablet, Nystatin (Antifungal) 1 Billion Unit Powder, Vitamin C (Supplement) 500 mg oral tablet, Vitamin D3 (Supplement) 50 mcg oral tablet. During the home visit with Patient 3 on 3/4/2026 @9:30 AM, Surveyor 2 notified of multiple discrepancies for Patient 3 on Medication profile. Patient 3 stated she was only taking Gabapentin, Furosemide, and Baclofen, plus her supplements (Mag, Calcium, Azo Cranberry, Vitamin D, Vitamin C, Multivitamin). The Patient showed Surveyor 2 her medication bottles and Surveyor reviewed her current medications with what was on the agency medication profile. Surveyor 2 asked if she was taking Methocarbamol, which was on the med profile but not provided to the surveyor. The patient stated she was not and she did not recall ever taking the medication. Surveyor 2 asked if she was taking Lyrica for nerve pain, which again was on the list but not with the Patient’s meds, and she again stated she was not and did not recall taking that medication. Surveyor 2 asked if she was taking Florajen Acidophillus, which is a probiotic that was also on her medication list. Surveyor 2 pulled up a picture of this medication on her phone, and the Patient said she did not take that. Surveyor 2 asked how long she had been taking the Gabapentin. She said she only takes it as needed, but she has been taking it on and off for the last 10 years. She confirmed her dose was 100mg nightly, which matched the label on the prescription. She stated she had taken it nightly for the last two weeks but was taking it less often now since it made her sleepy. She also stated she had been taking Lasix for a very long time, and that her dose was 20mg and she took 2 tablets once a day. She stated she had also been on Baclofen for 10 years and confirmed her dose was 5mg twice daily. Surveyor 2 stated the Medication Profile had her dose as 10mg - 1 tablet, two times a day and asked if her dose had changed recently. She stated it had not changed recently, and she had been taking 5mg twice daily as long as she could remember. Surveyor 2 asked RN D when she had last done a medication reconciliation with the Patient. RN D stated she did her recertification on 1/6/26 but “probably just asked if there were any changes” instead of looking at the Patient’s medication bottles. Interview with RN D conducted in parking lot conducted at 10:45 AM on 3/4/26. RN D stated, “I know I messed up with the medications. I know we should be pulling them out and looking at them every time. But it is hard to do with some Patients, because they don’t have them ready for you each time, and sometimes they are not used to having to go through them all each visit and will get annoyed with you.” Surveyor 2 asked why it’s important to ensure the medication list is up to date on each visit. RN D responded that it is important because they need to be able to know what medications each Patient is on so they can appropriately monitor and educate on side effects and monitor whether the med is working. During the home visit with Patient 1 on 3/4/2026 at 1 PM, Surveyor 1 requested to see Patient 1 medication list and compared to the current medication list. During the observation the surveyor found medications that were not included on the patient’s home medication list but were on the current agency medication list. Surveyor 1 asked the Patient about medications Meloxicam 7.5 mg and Gabapentin 100 mg (on active medication list). The patient stated, “I have not been taking those pain medications, I am weaning myself off, so I feel better. I still have the medications at home, but currently I am not taking them.” Surveyor 1 asked the Patient how long she had “weaning off” the medications, and Patient 1 responded, “I want to say maybe 2-3 weeks, my pain doctor prescribed them, but they seem to make me more vulnerable to a fall, so decided to stop taking them.” An interview with RN D was conducted following visit outside of home at 2:00 PM on 3/4/26. RN D stated, “Patient 1 does not provide all the details from her medication changes, especially due to the number of doctors’ appointments she has ongoing. She also makes medication changes on her own, without doctor orders, therefore when we go over her medications, they seem to be different most of the time. I try to go over her medication lists each visit, but she doesn’t always provide all the details on her care at the visit.” Record review of the policy titled “Medication Management,” last reviewed on 1/1/2026, revealed that “medication assessments will identify all medications, both prescriptions, non-prescription and as needed (PRN) that the Patient is taking and document in the clinical record. The Agency will ensure that assessments of a patient include a review of the medication regimen. This will include, but is not limited to…” In an interview with SN regarding medication profile on 3/5/2026 at 10:45 AM, Surveyor 1 asked what the agency’s policy was on keeping an up-to-date medication profile in the clinical record. The SN stated, “Our policy is that they (the clinicians) pull the meds out to the table and go over all the meds with the Patients on each visit. We educate them very frequently during clinical in services, case conference, etc. It is something we have been working on because we know it is an area where we can improve.” The Surveyor asked why having an up-to-date medication list for each Patient was important. The SN stated: “We want the list in their folder to be up to date if they need care from any other provider, if EMS must come or they go to the ER they can easily grab their med list and med bag, for emergencies, etc. Take 10 minutes to look at it, it could change the patient’s life.” In an interview with the Administrator on 3/5/2026 at 11:00 AM, Surveyor 1 notified her that Patient 1 had Gabapentin and Meloxicam on her medication profile, however the patient did not include this on her home medication listing and stated she had been “weaning off” of both the medications. The Administrator stated that “[Patient 1] was seen a few weeks back by myself, where I completed a medication reconciliation for all her medications and while in the home I updated her medication list for her records. Patient 1 tends to make changes to her medications on her own and then when the nurse comes for the home visit her medication list has changed, not necessarily by the Doctor.” Surveyor 1 asked Administrator if education was provided to the patient on the importance of following Doctor orders, and the danger of making medication changes on her own? Administrator responded, “yes, we have educated [Patient 1] on how important it is to take her medications as prescribed and how the medication list must be up to date due to interactions that can occur if she is taking something that has not been prescribed or updated as well.” The Administrator also included, “I believe in keeping the patient safe, so I continue to update the patient packet in the home at every visit to confirm all the medications are current, as well as any changes have been made.” During the interview with the Administrator at 11:45 PM on 3/5/26, Surveyor 1 asked what the agency’s policy was on keeping an up-to-date medication profile in the clinical record. The Administrator stated that the expected process was that they [the clinicians] should be going through the medications with the Patients each time. The Administrator stated that “the problem is that sometimes the Patients will say they are taking medication on one visit, and on the next visit they may say they have never taken that medication.” The Administrator stated that the clinicians need to make sure the Patients are taking their ordered medications and they should be communicating with the doctor if the Patient has stopped taking medications. Surveyor 1 asked how having an up-to-date medication list for each Patient could affect Patient care. The Administrator stated that each clinician needed to know exactly what their patients were taking and why they were taking it. She stated that it could harm the patient if they are taking something that the agency did not know about because “they need to know that they are taking the rights meds and being taken care of.” The Administrator stated that, “this is a service we need to provide because a lot of our patients are older and cognitively impaired and get confused about their medications.” Review of the policy titled “Medication Management,” last reviewed 1/1/2026, revealed that “medication assessments will identify all medications, both prescriptions, non-prescription and as needed (PRN) that the patient is taking and document in the clinical record. The Agency will ensure that assessments of a patient include a review of the medication regimen. This will include, but is not limited to…””