Every finding on record at Rgv Calidad Home Health LLC

Upon observation during 1 of 4 home visits, there was no evidence that: Patient 1: There is no evidence of a name badge worn by aide during home visit.

Upon patient record review, 2 of 19 (Patient #1 and 4) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1: Upon Home visit Daughter reports "she no longer takes Lisinopril and Liothyronine. Her doctor stopped these medications a few weeks ago. She is now taking Levothyroxine 100 mcg, HCTZ 25mg and insulin." There is evidence of these medications in the home with bottle dated 2/18/26 and no evidence on the medication profile dated 3/29/26. Patient 4: There is no evidence of medication Gabapentin in home and patient reports "I do no take Gabapentin." There is not evidence of Oxygen, Albuterol and Fluticasone on the medication profile 03/09/26 and patient reports utilizing medications during home visit.

Upon patient record review, 2 of 19 (Patient #1 and 4) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient 1: Upon Home visit Daughter reports "she no longer takes Lisinopril and Liothyronine. Her doctor stopped these medications a few weeks ago. She is now taking Levothyroxine 100 mcg, HCTZ 25mg and insulin." There is evidence of these medications in the home with bottle dated 2/18/26 and no evidence of updated orders for these changes. Patient 4: There is no evidence of medication Gabapentin in home and patient reports "I do no take Gabapentin." There is not evidence of physician orders for the Oxygen, Albuterol and Fluticasone and patient reports utilizing medications during home visit.

Upon patient record review, 4 of 19 (Patient # 1, 6, 7 and 9) did not have evidence in the patient record that hospice aide assignments and duties are: Patient 1: The Aide POC 12/29/25 does not contain evidence of detailed instructions for tasks including patient's functional limitations, DME, supplies and activities permitted. Patient 6: The Aide POC at SOC on 12/19/25 does not contain evidence of detailed instructions for tasks including patient's functional limitations, DME, supplies and activities permitted. Patient 7: The Aide POC on 3/26/26 contains evidence of PRN orders for tasks including "shave and nail care as needed." Patient 9: The Aide POC on 02/21/26 contains evidence of PRN tasks for aide to "assist in transfer and turn and reposition as needed."

Upon patient record review, 3 of 14 (Patient #6,7,10) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #6: Medication profile not updated for discontinuation of Medrol pack 4 mg 1 pill x 7 days ordered 1/26/23. Still present on 4/12/23 on the med profile. Patient #7: Oxygen 2-5 LPM prn sob on POC 12/8/22 but not listed on medication profile. Patient #10: Azithromycin 250 mg denoted that patient was taking on 1/24/23 and 1/27/23 as ordered by physician. No evidence that medication appeared on medication profile.

Upon patient record review, 1 of 14 (Patient #2) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patient #2: No evidence of bereavement risk assessment performed on this patient since admission.

Upon patient record review, 1 of 14 (Patient #9) did not have evidence the plan of care must includes all services necessary for the palliation and management of the terminal illness and related conditions, including the following: • A detailed statement of the scope and frequency of services necessary to meet the specific patient and family needs • The IDG demonstrates a proactive approach in developing each patient's plan of care by planning ahead for anticipated patient changes and needs. Decisions should reflect the patient/family preferences rather than be solely a response to a crisis. Patient #9: Plan of care lists frequency as MSW PRN. No evidence of frequency or duration.

Upon patient record review, 1 of 14 (Patient #10) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patient #10: Azithromycin 250 mg denoted that patient was taking on 1/24/23 and 1/27/23 as ordered by physician. No evidence that medication appeared on orders nor on plan of care.

Upon client record review, 6 of 14 (Patient #2,4,5,8,9,13) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #2: POC dated 12/20/22 orders chaplain within 5 days of SOC, CH visit performed 12/28 outside the 5 day window with no evidence of order to change frequency. Patient #4: 3/9/23 order for SN to perform wound care as cleanse with NS, Pat dry, apply betadine, place alginate between toes. SNV of 3/15 did not perform wound care as ordered but performed wound care as cleansed with NS, patted dry, applied TAO. Patient #5: Physician order on 3/26/23 does not order a chaplain frequency. Chaplain made visit on 3/29/23 without an order. Patient #8: Physician orders dated 3/3/23 state MSW 1m1, MSW made visit 3/3/23 and 4/1/23. Patient #9: 2/17/23 POC orders SN as 1w8, 1w7 and 7 prn. No evidence of missed visit for first week of episode. No evidence of order to change frequency. Patient #13: MSW ordered 1m4 on POC 11/30/22. No evidence of missed visit or change of order for missing November visit.

Upon patient record review, 1 of 14 (Patient #1) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Aide assignment of 3/15/23 does not include oxygen precautions for patient on oxygen.

Upon patient record review 2 of 14 (Patient #1, 2) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient #1:Aide assignment dated 3/15/23 assigned both catheter care and incontinent care. Aide did not perform these tasks 3/15, 3/22, 3/23/23. Patient #2: Aide assignment on 3/20/23 assigns shave 1x week. Aide documented shaving patient 3/20/23, 3/21, 3/22, 3/23, 3/24.

Upon personnel record review, 1 of 10 (Personnel #3) did not have evidence that all personnel have been fully vaccinated for COVID-19. Personnel #3 There was no evidence in the personnel record of Covid Vaccination or an approved exemption.

Based on record review and interview the agency Skilled Nurse failed to include a MAR on the initial Comprehensive assessment for 1 of 1 discharged patient (Patient #1) whose record was reviewed. This failure places the agency's active patients at risk for adverse drug interactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. The Findings Included: Review of the electronic clinical record for Patient #1 revealed a start of care date of 12/08/21, with a diagnosis of Malignant Neoplasm of Connective and Soft Tissue. Continued review of the electronic clinical record for Patient #1 revealed the initial Comprehensive assessment which was dated 12/08/21 and signed by RN A. Continued review of the initial comprehensive assessment revealed that the section titled "Medication Administration Record" was left blank. Still further review of the electronic clinical record for Patient #1 revealed a Discharge Summary which was dated 12/14/21 and was signed by RN A. Continued review of the Discharge Summary revealed a "Current Medication Profile at Discharge" it listed 13 medications, with start date, medication, rout, form, strength, dose and frequency. An Interview was conducted on 12/16/21 at 10:46 a.m. with RN A review of the electronic clinical record was done, after review RN A, agreed with the following: -The Medication Administration Record was not completed during the initial comprehensive assessment. -A review of all the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments were not documented on the initial Comprehensive Assessment. -A review of the Effectiveness of drug therapy, Drug side effects, Actual or potential drug interactions, Duplicate drug therapy and Drug therapy currently associated with laboratory monitoring were not documented on the initial Comprehensive Assessment. Review of the Agency's Policy and Procedure Manual revealed a policy titled "Initial Patient Assessment/Patient Admission", it was numbered PE.3 and had a revision date of 02/16/20. It read in part: "A Registered Nurse will complete the Initial Health Assessment." Continued review of the Initial Patient Assessment/Patient Admission policy read in part: "H. The initial Comprehensive Health Assessment, with input from appropriate IDT members and the attending physician will include the following: "Medication history, Medications currently prescribed, Medication compliance history, Side effects, drug allergies, sensitivities and past adverse drug reactions actual or potential interactions, Effectiveness of drug therapy, Food and environmental allergies, Duplicate drug therapy and Drug therapy currently associated with laboratory monitoring." Continued review of the Initial Patient Assessment/Patient Admission policy read in part:" The initial assessment data/information will be gathered and documented on the following forms: Medication Record Form." Review of the Agency's Policy and Procedure Manual revealed a policy titled "Medication List and Monitoring", it was numbered TX.20 and had a revision date of 10/01/15. It read in part: "A medication profile will be maintained on all patients. Medication monitoring will include appropriated date/information to develop an accurate medication history and current complete medication profile." Continued review of the Medication List and Monitoring policy read in part: "Agency will maintain a current, accurate list of all prescription and over-the counter medications taken by the patient."