Every finding on record at Joshua Tree Healthcare, Inc.

The following reflects the findings of the California Department of Public Health during a standart recertification survey conducted on July 22,2025 through July 25, 2025. The inspection included the Emergency Preparedness requirements under CFR §483.73(b)(6)-E0024. The facility was found to be in compliance with CFR 42 483.73 (b) (6), Requirements for Emergency Preparedness for Home Health Agency (HHA). The Home Health Agency's unduplicated census: 595 Current census: 55 Patients The sample size: 13 Patients Record review with home visits: 5 Patients Record review without home visits: 4 Patients Closed record review: 4 Patients

The following reflects the findings of the California Department of Public Health during a recertification survey conducted from July 22, 2025 through July 25, 2025. Total unduplicated admission within the last year: 595 patients Active Patient Sample: Record Review Only (no home visits) - Four Patients Active Patient Sample: Record Review with Home Visit - Five Patients Discharge Patients: Closed Record Review - Four Patients Total Survey Sample: Thirteen Patients Agency's Current Active Census: 55 Patients

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 failed to ensure the clinical record contained an accurate comprehensive medication profile, for one of 13 sampled patients (Patient 13) when the mediation profile did not accurately reflect the medications Patient 13 were taking in the home. This agency’s failure had the potential to put the patients at risk for medication errors, adverse drug reactions, and ineffective drug therapy. Findings: On July 24, 2025, Patient 13’s medical profile was reviewed. Patient 13 was admitted to the home health agency on May 12, 2025, with a primary diagnosis of age related osteoporosis (a condition where bones become weaker and more prone to fractures). The certification period reviewed was July 11, 2025, through September 8, 2025. On July 24, 2025, at 7:30 a.m., during a home visit conducted with the Home Health Aide (HHA 1), Patient 1's "Client Medication Report," indicated a physician's order for Gabapentin (medication for nerve pain) 100 mg (milligram – unit of measurement), 1 capsule, oral, at bedtime. Patient 13's medications located on top of the his counter was observed to not have Gabapentin on the counter. In a concurrent interview with Patient 13, Patient 13 stated he had not taken Gabapentin for a long time; he did not know why the medication was still listed on his medication list with home health. On July 25, 2025, at 10 a.m. an interview was conducted with the Director of Patient Care Services (DPCS). The DPCS stated all the patient’s medications should be reconciled at time of admission and on a regular basis. The DPCS further stated she did not know why the medication was still on the plan of care. A review of the policy and procedure titled, “Medication Profile” dated April 2018, indicated,”…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 regimen…using medication profile to evaluate the use of medications in the home setting. The medication profile includes, but is not limited to all current medications, date prescribed, name of medication, does frequency, drug classification date discontinued and drug and /or food allergens…”

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure physician’s verbal orders were signed and dated timely, within 30 days of the order date, for one of thirteen patients reviewed (Patient 2). This failure resulted in verbal orders not being authenticated and dated by the physician in accordance with the agency’s policy and procedure. This failure also had the potential to result in incorrect verbally ordered medications, and treatments for patients which could cause unnecessary care and services. Findings: On July 24, 2025, during a record review of Patient 2’s record, the record indicated Patient 2 was admitted to the agency with a Start of Care (SOC) date of April 13, 2023, with a diagnosis of cystostomy (an opening in the urinary bladder for drainage), and colostomy (opening in the abdominal wall to allow the colon to pass waste through the body). The "Plan of Care (POC)," dated May 28, 2025, signed by the Registered Nurse for the certification period from June 1, 2025, through July 30, 2025, indicated the POC was not signed by the primary care physician until July 1, 2025, 35 days past the order date. On July 25, 2025, at 11 a.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated the physician for Patient 2 should have signed the POC within 30 days of the order date. A review of the agency’s policy and procedure titled, “Verification of Physician Orders,” dated April 2018, indicated”…signed orders will be in the clinical record within 30 days of initiation of care or interim order, unless otherwise specified by applicable state law and regulation…”

In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure expired medical supplies were not readily available for use. In addition, the annual tuberculosis (TB), a Purified Protein Derivative [(PPD) a skin test for tuberculosis]) screening was not completed in a timely manner for four of eight staff reviewed. This agency's failure increased the potential for expired medical supplies to be used for patients and the potential to delay the recognition of positive testing placing the patient and staff at risk for a possible infection. Findings: 1.On July 25, 2025, at 11 a.m., an inspection of the medical supply room was conducted, and the following medical supplies were observed expired or stored beyond their expiration dates and readily available for use: - Expired Red top serum collection tubes for collecting blood; - Expired Blue Top coagulation tubes for collecting blood; - Expired Light Green Lithium separator tubes for collecting blook; - Expired Yellow SST serum collection tubes for collecting blood; - Expired Lavendar top EDTA collection tubes for collecting blood and; - Two (2) Dura Fiber Wound Coverings On June, 2025, On July 25, 2025, at 11:20 a.m., a concurrent observation and interview was conducted with the Director of Patient Care Services (DPCS). The DPCS confirmed the medical supplies were expired and should have already been discarded. A review of the agency's policy and procedure titled," Expiring Supplies in California" undated, indicated"...home health agencies should not use expired medical supplies on patients...reduced effectiveness and harm; using expired supplies carries risks, including decreased effectiveness, potential chemical changes, and increased risk of infection, according to the American Red Cross...consequence using expired supplies could lead to adverse patient outcomes, legal liabilities, and damage to the agency's reputation..." 2. On July 25, 2025, employee files were reviewed. Four (4) of eight (8) staff personnel files indicated the following: - The speech therapist record indicated no TB screening was conducted at the date of hire on July 11, 2022. There was no subsequent TB testing as well annually; and - Three staff records (Social Services Manager, Home Health Aide, and Licensed Vocational Nurse) no updated annual TB testing as indicated below: a. The Social Service Manager file indicated the last TB testing was completed on April 24, 2024; b. The Home Health Aide file indicated the last TB testing was completed on May 27, 2024; and c. The Licensed Vocational Nurse file indicated the last TB testing was completed on June 17, 2024. On July 25, 2025, at 10:30 a.m., an interview with the Director of Clinical Services (DPCS), was conducted. The DPCS stated it was the expectation all staff complete the TB testing annually. The DPCS further stated the TB testing should have been completed in a timely manner to ensure safety for all staff and patients. A review of the facility’s policy and procedure titled, “Selection/Hiring of Personnel,” dated 2009, indicated, “…an offer of employment will be contingent upon a current physical and TB test/chest xray (digital image of the internal composition of something, especially a part of the body)...the annual tuberculosis screening requirements…documentation of these tests will be maintained in the personnel health file…”

Social Worker CFR(s): 484.115(m) Standard: Social worker. A person who has a master's or doctoral degree from a school of social work accredited by the Council on Social Work Education, and has 1 year of social work experience in a health care setting. This STANDARD is not met as evidenced by: Based on interview and personnel record review, the agency failed to adhere to the agency's job description and policy regarding social worker requirements for hiring. The failure had the potential for the patients to not receive the appropriate care needed. Findings: On July 25, 2025, a review of one of eight staff personnel files was conducted. A review of the Social Service Manager’s file indicated no licensure with the Board of Behavioral Sciences. On July 25, 2025, at 10:30 a.m., an interview and concurrent record review were conducted with the Director of Clinical Services (DPCS). The DPCS stated the Social Services Manager did not have a license and had not been overseen by a licensed clinical social worker. The DPCS stated the social services manager should be licensed or have oversight by a licensed social worker. A review of the social service manager “Job Description” in the personnel file, indicated, “…unlicensed social worker shall inform each patient prior to performing any such function that…is not licensed clinical social worker and is under the supervision of a licensed clinical social worker…will be supervised face to face by a qualified Licensed Clinical Social Worker (LCSW) for one hour per week…” A review of the agency's policy and procedure titled, “ Personnel Administration,” dated 2009 indicated, "...Social Worker…licensed as a licensed clinical social worker by the Board of Behavioral Sciences…”

The following reflects the findings of the Department of Public Health during a Recertification Survey.Representing the Department of Public HealthSurveyor ID #- 25046 RN-HFEN Surveyor ID #- 22303 RN-HFEN Unduplicated Admissions -15Active Patients - 4Sample Size - 7 PatientsHome Visit - 3

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 agency's staff failed to review all medications and update the medication profile with currently used medications for two of seven sample selected patients (Patients 1 and 5). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: During a review of Patient 5’s Plan of Care (POC) for the certification period from 2/5/2022 to 4/5/2022, indicated a Start of Care (SOC) date of 8/9/2021, with diagnosis that include Malignant neoplasm of upper outer quadrant of right female breast (breast cancer), quadriplegia (unable to move both arms and legs), Cervical spinal cord injury, and pulmonary hypertension. The POC included for the Skilled Nurse (SN) to visit one time a week for one week then one time per week every two weeks. The SN to provide medication regimen and to instruct impact of polypharmacy. During a review of Patient 5’s Care Giver’s 1 (PCG 1) Medication and Supplement notes dated March 2022 on 3/22/2022 at 9:15 a.m. indicated Patient 5 was taking “Potassium (1 pill – PM) and Gabapentin (one pill nightly 100mg). During a telephone interview on 3/24/2022 at 9:31 a.m. with Patient 5’s CG, CG stated that Patient 5’s Pulmonologist prescribed Potassium 8 milliequivalent (mEq) 1 tablet daily sometime in 2019 and was last filled on 2/19/2022. During a joint home visit to see Patient 5 on 3/22/2022 at 9 a.m. with Registered Nurse 2 (RN2), Patient 5 was sitting on wheelchair and Patient Care Giver 1 (PCG 1) was next to Patient 5. Patient 5 was alert and oriented, and able to communicate well. During a concurrent interview and record review on 3/22/2022 at 9:20 a.m. with RN 2, of Patient 5’s the medication profile provided by the agency was reviewed. The following medications were noted: 1. Breo Ellipta 100 mcg-25 mcg dose powder for inhalation, 1 inhalation daily. 2. Calcium 500 mg, 3 tablets daily oral. 3. Curamin 2,706 mg, 1 tablet daily by mouth. 4. D-Mannose Powder Plus 2000 mg, 2 teaspoon daily by mouth. 5. Eliquis 5 mg, 1 tablet, 2 times daily oral. 6. Faslodex 250 mg/5 ml intramuscular syringe, 5 ml monthly. 7. Flonase allergy relief 50 mcg actuation naseal spray suspension, 1 spray daily nasal. 8. Lasix 20 mg, 1 tablet daily oral. 9. Melatonin 5 mg tablet, 2 tables bedtime oral. 10. Midodrine 5 mg tablet, 1 tablet daily oral as needed. 11. Miralax 17 gram/dose oral powder, 8.5 grams daily oral. 12. Multaq 400 mg tablet, 1 tablet, 2 times daily oral. 13. Omega 3-6-9 1,200 mg capsule, 1 capsule daily oral. 14. Preservision areds 14,320 unit-226 mg-200 unit capsule, 1 capsule daily oral. 15. Probiotic 10 billion cell capsule, 1 capsule daily oral. 16. Prolia 60 mg/ml subcutaneous syringe, 1 ml as directed subcutaneous. 17. Swess Kriss 8.5 mg/1.5 TSP, .25 oz daily by mouth. 18. Tramadol 50 mg tablet, 1 tablet bedtime oral. 19. Vitamin D2 1,259 mcg (50,000 unit) capsule, 1 capsule weekly oral. During a record review of Patient 5’s Physician Order with an order date of 3/21/2022 at 7:07 PM, indicated Gabapentin 100 mg capsule, 1 capsule every PM oral and Potassium Chloride ER 10 mEq 1 tablet every PM oral. A review of facility’s policy and procedure titled, “Medication Profile” undated indicated, “Patient receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, new and/or discontinued medications. Procedure: 3C. Using the mediation profile as a communication tool for other clinicians involved in the care. 5. Based on review of the medication profile as well as the written material, changes in the plan of care may be required. A review of Patient 1's Patient Information indicated, a start of care (SOC) date of 12/9/21, with diagnosis that included acute respiratory failure (occurs when fluid builds up in the air sacs in the lungs). During a review of Patient 1's Plan of Care (POC), for the certification period from 2/7/22 to 4/7/22, included an order for skilled nurse (SN) to visit twice a week for 8 weeks, one week for one week. The POC indicated the SN was to review the patients medication regimen and provide education. Patient 1's medication profile dated 2/10/22, included Lasix 20 milligrams (mg) every other day for edema. On 3/22/22, at 12 p.m., a home visit was conducted at Patient 1's residence with the Registered Nurse 1(RN). During a review of Patient 1's medications indicated a bottle of Lasix 20 milligrams (mg) every other day. On 3/22/22, at 12:10 p.m., during an interview with Patient 1, he stated he was not taking the Lasix medication for a week per his physician's instruction. On 3/22/22, at 12:30 p.m., during an interview with RN 1, she stated the medications should be checked every visit with the medication profile to ensure its accuracy. She further stated that she would ask patient if patient still taking medications as ordered.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview and record review, the agency staff failed to follow the written plan of care established by the physician that included a Stage II left buttocks wound (a break in the top two layers of skin) assessments for one of seven sample selected patients (Patient 1). This deficient practice has the potential in the delay of healthcare response, treatment, and intervention that could result to complications to an already compromised patient's health status. Collapse During a review of Patient 1's Plan of Care (POC), for the certification period from 2/7/22 to 4/7/22, included an order for skilled nurse (SN) to visit twice a week for eight weeks, one week for one week. The POC indicated the SN was to assess skin status to identify changes and intervene to minimize complications, to provide wound care treatment to Stage II left buttocks as follows: to cleanse with wound cleanser, apply a moisture barrier, cover with foam bandage using aseptic technique. On 5/22/22, at 11 a.m., a home visit was conducted at Patient 1's residence with Registered Nurse (RN 1). Patient 1 was observed to have a Stage II left buttock pressure wound that was covered by a soiled dressing. A review of Patient 1's Visit Note Report dated 3/14/22 and 3/16/22, indicated there was no documented evidence of Patient 1’s Stage II left buttocks pressure ulcer was assessed and measured. During an interview with the Director of Patient Care Services (DPCS), on 3/23/22 at 11:30 a.m., she was not able to provide the documented evidence the Stage II left buttocks pressure ulcer was assessed on 3/14/22 and 3/16/22 visits. A review of the agency’s undated policy titled “Wound Assessment and Documentation” indicated to assess the wound location and its size; measure the length, width, and depth.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency staff failed to inform the physician promptly of any changes in patient's condition for one of seven sample selected patient (Patient 1). This failure had the potential in the delay of treatment that could affect the patient's health care status. During a review of Patient 1's Plan of Care (POC), for the certification period from 2/7/22 to 4/7/22, included an order for skilled nurse (SN) to visit twice a week for eight weeks, one week for one week. The POC indicated the SN was to observe, assess regarding peripheral edema (occurs when excess fluid builds up in the body, causing swelling) to identify changes and intervene to minimize complications. On 3/22/22, at 11 a.m., a home visit was conducted at Patient 1's residence with RN 1. Patient 1 was observed sitting on a couch with a swollen right foot. When Patient 1 was asked, he stated his right foot started swelling two days ago. On 3/22/22, at 11:15 a.m., when RN 1 was asked about Patient 1's swollen right foot, she stated the patient's right foot was not swollen during her previous visit. She also stated that Patient 1 has a +3 pitting edema and she will notify the physician right away. On 3/23/22, at 11:30 a.m., during a record review of Patient 1's clinical record, indicated there was no documented evidence Patient 1's physician was notified regarding new existing +3 pitting edema on right foot. During an interview with the Director of Patient Care Services (DPCS), on 3/23/22 at 11:40 a.m., she was not able to provide the documented evidence the physician was notified about Patient 1's right foot +3 pitting edema. The HHA's undated policy & procedure titled, "Care Planning Process," indicated the clinicians will inform the patient's physician of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes.

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 agency failed to provide a copy of written instructions outlining the visit schedule and medication schedule/instructions to two of seven sample selected patients (Patient 4 and Patient 5). This failure had the potential to result in patients not knowing their prescribed visit schedule and medication schedule/instructions/regime. Findings: During a review of Patient 4’s Plan of Care (POC) for the certification period from 2/8/2022 to 4/8/2022, indicated a Start of Care (SOC) date of 2/8/2022, with diagnosis that include Chronic peptic ulcer with hemorrhage (occur when stomach acid damages the lining of the digestive tract and bleeding), essential hypertension (high blood pressure), restless leg syndrome, and low back pain. The POC included for the Skilled Nurse (SN) to visit two time a week for one week then one time per week for three weeks, and one time a week every two weeks. The SN to provide medication regimen and to instruct impact of polypharmacy (too much medication). During a joint observation home visit, on 3/22/2022 at 10:30 a.m., with Registered Nurse 2 (RN2), Patient 4 was ambulating without difficulty. Patient 4 was alert and oriented, and able to communicate well. During an interview, on 3/22/2022 at 10:40 a.m., Patient 4 stated that the Home Health Agency (HHA) nurse dropped off papers last night, which Patient 4 found on her porch this morning. Patient 4 provided the papers that were dropped off, which included her POC and Medication Profile. During an interview, on 3/22/2022 at 10:50 a.m. Registered Nurse 2 (RN 2) stated that the nurse delivered the POC and the Medication List last night. RN 2 stated that there was no POC or Medication Profile prior to last night in Patient 4’s HHA home folder. During a review of Patient 5’s Plan of Care (POC) for the certification period from 2/5/2022 to 4/5/2022, indicated a Start of Care (SOC) date of 8/9/2021, with diagnosis that include Malignant neoplasm of upper outer quadrant of right female breast (breast cancer), quadriplegia (unable to move both arms and legs), Cervical spinal cord injury, and pulmonary hypertension (high blood pressure that affects the arteries in the lungs). The POC included for the SN to visit one time a week for one week then one time per week every two weeks. The SN to provide medication regimen and to instruct impact of polypharmacy. During a joint observation home visit, on 3/22/2022 at 9 a.m. with RN2, Patient 5 was sitting on wheelchair and Patient Care Giver 1 (PCG 1) was next to Patient 5. Patient 5 was alert and oriented, and able to communicate well. During an interview, on 3/22/2022 at 9:20 a.m., PCG 1 stated that the HHA nurse dropped off papers (referring to the POC and Medication Profile) last night. During an interview, on 3/22/2022 at 9:30 a.m., RN 2 stated that the nurse did deliver the POC and the Medication List last night. RN 2 stated that there was no POC or Medication Profile prior to last night in Patient 5’s HHA home folder. A review of facility’s policy and procedure titled, “Care Planning Process” undated indicated, “The care planning process will be documented on the plan of care, individualized discipline specific care plans, clinical notes, medication profiles, care conference/summary forms, and discharged/clinical summaries. Procedures: 2C – All clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including but not limited to: Clinical drug monitoring, as appropriate. 3K – Based on the assessment and conclusions, the plan of care will include, but will not be limited to: All medications.16B – The organization shall provide the patient and caregiver with a copy of written instructions outlining: Patient medication schedule/instructions, including medication name, dosage and frequency and which medications will be administered by the organization’s personnel and personnel action on behalf of the organization.