Every finding on record at Angelus Health Services, Inc.

A re-licensure and recertification survey was conducted on 06/03/2025. The census was 17 (L&C) 19 (LHHS), and (0) PAS. Abbreviations used: >- greater than Admin- Administrator AA- Alternate Administrator ADON- Alternate Director of Nurses BS- Blood Sugar DON- Director of Nurses dl- deciliter EMR- Electronic Medical Record ER- Emergency Room FBS- Fasting Blood Sugar HHA- Home Health Agency L&C- Licensed and Certified LHHS- Licensed Home Health Services MAR- Medication Administration Record MD- Medical Doctor Mg-Milligram ML- Milliliter OASIS- Outcome Assessment Information Set POC- Plan of Care RBS- Random Blood Sugar SOC- Start of Care RN- Registered Nurse SN- Skilled nurse SNV- Skilled Nurse Visit T2DM- Type II Diabetes Mellitus VA- Veteran’s Administration

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 interview, and record review, the agency failed to ensure all medications currently used by the Patient were reviewed by a skilled professional for 1 of 7 active patients whose record were reviewed (Patient #1) in that: The agency did not perform a drug regimen review that accurately reflected all the medications Patient #1 was currently taking and discharged from the hospital with. RN #1 failed to follow initial referral orders upon admission for certification period from 05/26/2025-07/24/2025 for Client#1 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included insulin orders. RN B failed to follow insulin orders dated 05262025. This failure could place patients at risk of not receiving medications as ordered, deterioration, failure to improve or maintain health and staff not identifying any potential adverse effects and drug reactions, or duplicate drug therapy. Findings included: Review of active Patient #1 electronic medical record (EMR) revealed a skilled nursing services with certification plan of care (POC) from 05/26/2025-07/24/2025 with primary diagnosis of Type 2 diabetes mellitus w diabetic chronic kidney disease (type 2 diabetes mellitus(T2DM) refers to high blood sugar levels, while diabetic chronic kidney disease is kidney damage caused by T2DM, Low vision right eye category 1, low vision left eye category 1 (low vision refers to chronic visual impairments that cannot be corrected with glasses, contact lenses, or medical or surgical treatment), Long term (current) use of insulin (the ongoing use of insulin in patients who require it for the management of diabetes mellitus), Type 2 diabetes w/ unspecified diabetic retinopathy without macular edema (means that a person had T2DM and is at risk of developing diabetic retinopathy without macular edema. A condition where high blood sugar levels cause damage to blood vessels in the retina. These blood vessels can swell, leak, or close, leading to changes that can affect vision), End stage renal disease (last stage of chronic kidney disease and which can be treated with dialysis or kidney transplant), and Dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. When kidneys are damaged, they are no longer able to remove wastes and excess fluid from the bloodstream efficiently). Further review of the POC revealed orders for skilled nursing (SN) once a day for 60 days, and 1-2 additional visit(s) as needed for disease process exacerbation, complications, and post-fall assessment. A. SN for comprehensive assessment each visit: 2. Current medications (review and reconcile); patient/caregiver ability to manage medication and treatment regimens. 3. Medications: dose, route, frequency, purpose, side effects, potential adverse reactions, ineffective drugs for reporting, medication regimen compliance - filling pillbox properly. B. SN to teach/train patient/caregiver where knowledge deficit noted: 10. All aspects of diabetes management, diabetic retinopathy with macular edema to include disease process, skin, foot assessments and care, signs and symptoms of hypo/hyperglycemia, diet and hydration, exercise/activity, glucometer (a medical device for determining the approximate concentration of glucose in the blood) use, preparation and administration of diabetes medications including rotation of injections sites ordered by physician. SN to administer Insulin Glargine Subcutaneous (a long-acting modified form of medical insulin)100 unit/ML, Pen 3 ML under the skin daily with 5 units. Patient unable to manage and administer medication due to poor visions, had trouble checking blood sugar, unable to tell markings on insulin syringes. Obtain fingerstick fasting blood sugar (FBS) or random blood sugar (RBS) every visit and as needed if patient unable/unwilling or reports hypo/hyperglycemia. SN to perform inspection of patient's lower extremities every visit and report any alteration in skin integrity to physician. C. SN interventions within the current certification period: 1. Medication review, reconciliation every visit. 9. SN to administer Insulin Glargine Subcutaneous 100 unit/ML, under the skin daily with 5units. Patient unable to manage and administer medication due to poor visions, had trouble checking blood sugar, unable to tell markings on insulin syringes. Obtain fingerstick FBS or RBS every visit and as needed if patient unable/unwilling or reports hypo/hyperglycemia. SN to perform inspection of patient's lower extremities every visit and report any alteration in skin integrity to physician. Record review of Patient #1’s medication profile revealed the following orders: INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS (the lowermost layer of the integumentary system). Inject 5-10units subcutaneously daily for BS 200 mg/dL subcutaneously (to inject the lowermost layer of the integumentary system) per Medical Doctor (MD) orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 05/29/2025, revealed that RN B documented that Patient #1 was administered 6 units of insulin glargine to Patient Right-Abdomen via flex pen; Blood Sugar: 198; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 05/30/2025, revealed that RN B documented that Patient #1 was administered 5 units of insulin glargine to Patient Left-Abdomen via flex pen; Blood Sugar: 154; Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 05/31/2025, revealed that RN B documented Patient #1 was administered 5 units of insulin glargine to Patient Left-Abdomen via flex pen; Blood Sugar: 121; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 06/01/2025, revealed that RN B documented Patient #1 was administered 5 units of insulin glargine to Patient Right-Abdomen via flex pen; Blood Sugar: 211; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 06/02/2025, revealed that RN B documented Patient #1 was administered 5 units of insulin glargine to Patient Left-Abdomen via flex pen; Blood Sugar: 156; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. Record review of clinical record titled “Veterans Health Administration (VHA) Medical Documentation” dated 05/06/2025, revealed Patient #1 MD orders read in part … “Skilled Home Health Care... Procedural Overview: 1. All home health services listed below: 1A. Comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation…. MEDICATIONS… INSULIN, GLARGINE-YFGN 100UNIT/ML PEN 3ML…INJECT 5 UNITS UNDER THE SKIN DAILY FOR DIABETES. ACTIVE” Record review of RN A personnel file revealed a hire date of 07/09/2021. An agency document titled “Job Description/ Performance Evaluation- RN.” The document was signed by RN A dated 07/09/2021. A document was revealed titled “Employee Acknowledgment” was signed and dated 07/09/2021 by RN A. This document read in part... “I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.” An additional document titled “Orientation Checklist” that read in part… Section V Clinical Information… Communication and Documentation requirements was initialed and dated 07/09/2021 by RN A. Nursing clinical procedural manual was initialed and dated 07/09/2021 by RN A. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 03/31/2027. Record review of RN B personnel file revealed a date of hire for 03/28/2025. An agency document titled “Job Description/Performance Evaluation- RN.” The document was signed by RN B dated 03/28/2025. A document was revealed titled “Employee Acknowledgment” was signed and dated 03/28/2025 by RN B. This document read in part... “I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.” An additional document titled “Orientation Checklist” that read in part… Section V Clinical Information… Communication was initialed and dated 03/28/2025 by RN B. Nursing clinical procedural manual was initialed and dated 03/28/2025 by RN B. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 12/31/2025. RN A contacted and unable to reach. Message left. During a telephone interview with RN B on 06/05/2025 at 12:19 P.M. RN B indicated that he started about a couple of months ago with the agency. Stated that he had been a RN for 15 years. Stated that Patient #1 had been assigned to his care since admission. RN B reported that he performed SNV once a day. RN B indicated that his primary focus was the T2DM management. Stated that he performed random blood sugar level checks, and that he typically had to administers five to six units of the glargine long-acting insulin. Just once a day, usually in abdomen. RN B continued to state that Patient #1’s blood sugars were usually ranging from 110s to 180s; sometimes 190s. Surveyor inquired if Patient #1 had a sliding scale for her insulin or if she had orders for a specific daily dose. RN B explained that there's supposed to be a sliding scale, but Patient #1 always wanted the same 5 units. RN B stated that she didn’t want anything more than the 5 units. RN B stated that he convinced her she needed more when indicated. RN B continued to explain that usually it depended upon the nurses’ discretion; for example, if Patient #1’s blood sugar was way too high the RN could give more and continue to increase the insulin based on if it was too high over a period of couple days. Surveyor asked, “Is there a range for the blood sugar levels or how would the SN determine how much insulin to give?’ RN#2 stated that he recalls seeing an order that was if her FBS was 100 to 200, Patient #1 would get 5 to 10 units and if it's above 200 you can go 11 and above units. Surveyor asked, “How would a nurse know how much insulin to administer? When would the SN administer 5 units, 6 units, 7 units, and so on?” RN B stated that the RN must look at Patient #1 and determine if she is symptomatic. For example, if Patient #1 had symptoms and was looking like she had low blood sugar, and depending on the range of her level, then the RN decided how much to administer. The normal blood sugar for a person is 80 to 120. He stated that Patient #1 was not very compliant with her diet or medication. RN B continued to explain that basically as the SN, you have to play it by ear, and the SN would have to ask Patient #1, What did you eat? Attempt to find out if Patient #1 put another couple “extra spoonful of sugar in her tea.” Surveyor asked if RN B requested to or spoke to the doctor about Patient #1’s blood sugars or insulin orders. RN B stated that he relayed all the necessary information to the MD. RN B also stated that he sent all of Patient #1 vitals; RN B corrected his self and stated that he sent it to the agency’s office. He continued that he had not personally heard anything from the MD’s office. Surveyor asked if he knew what MD the information was sent to? RN B stated that he did not remember that information. Surveyor asked if he had ever obtained a blood pressure, that was outside of the parameters, what do you do? RN B stated that on 2 separate occasions I've given her extra medication. RN B stated that initially that Patient #1 refused to take additional medication but then when she was able to see that the medication worked for her, she took the extra medications when necessary. RN B stated that he put it all into the notes. RN B also stated that Patient #1 often refused any medications, any interventions, any visits to the VA, ER, anything. She refused everything. RN B stated that he put that in his notes and then he tried to tell her to do some stuff. For example, RN B encouraged Patient #1 to take deep breaths, relax, stop being so mad at everybody, and let her know everything will be ok. RN B stated that when he took the blood pressure again, like maybe 30-45 minutes later, it typically had improved. Surveyor: “At any time, have you ever communicated to the doctor when you got those blood pressures that were out of range?" RN B stated that he had communicated with the MD’s office regarding the blood pressure irregularities via the agency’s office. RN B stated that he notified the agency’s office, then the office sent the message to the doctor. And then usually, like by the time he gets home, he already saw the letter that it had been said because they forwarded it to him too. Surveyor asked if RN B knew what the agency’s policy was related to medication administration, medication orders, specifically order clarification, or plan of care implementation. RN B stated that he was not real sure off hand. Surveyor asked, RN B if he was aware of the potential adverse effects that medications error could have on the patient. RN B stated that the patient could become extremely ill. Interview with ADON on 06/05/2025 at 2:45 pm, ADON revealed that the agency policy was to perform a medication reconciliation and review with each comprehensive assessment which was every visit. The ADON continued that the admitting nurse used the hospital discharge orders and medications on hand to do the initial admission orders. Surveyor inquired if ADON was able to provide the surveyor with evidence of the source of the current insulin orders for Patient #1. The ADON reviewed the order and stated that she was unable to provide the source of the current insulin orders for Patient #1 because it was an incomplete order and should be clarified during the admission process. The ADON stated that the DON or ADON is ultimately responsible for ensuring that all the orders are correct in the patient’s clinical record. The ADON added that the admission and primary nurses have the initial responsibility of ensuring the order is correct. ADON stated that she was unable to say why the admission nurse RN A or the current primary nurse- RN B failed to clarify the orders. The ADON stated that the agency policy is to seek clarification of any unclear orders and can’t say why the nurses had not followed the agency’s policy. ADON also stated that all nurses were expected to follow all agency policies. Re-interview with RN B was attempted but unable to reach prior to exit. Record review of DON’s personnel file, an agency document titled, “Job Description/Performance Evaluation-Director of Nurses/ Alternate.” The box checked for the Director of Nurses indicating that this job description was for the Director of Nurses. The document was signed by the DON on 09/25/2013. Surveyor requested to interview the DON and the ADON stated that the DON remains unavailable at this time. ADON stated that it is the ADON responsibility to fill in for the DON when needed. Record review of the ADON’s personnel file, an agency document titled “Job Description/Performance Evaluation-Director of Nurses/Alternate.” The box checked for the Alternate indicating that this job description in for the Alternate Director of Nurses. The document is signed by ADON and dated 02/15/17. Interview with ADON on 06/05/2025 at 4:05 P.M. revealed that the ADON had read and understood her job description and expectations of her and the nurses that report to her. Surveyor questioned how she ensured that medication reconciliation happened with every visit. ADON stated that the DON and ADON constantly reminded the nurses to perform the medication reconciliation. ADON stated that the assigned RN who performed the admission, were reminded that it was the agency’s policy to perform medication reconciliation and to check the medications on hand. The ADON continued to say that she reminded the nurses when she knew that the patient did not have medication pill boxes. The ADON stated that her staff are encouraged to come to the office to get them to give to patients identified as needed one. The VA patients usually would ask for one. ADON stated again that she did not know RN A or RN B did not follow the agency’s clinical policies. Interview with AA on 06052025 at 4:48 P.M. revealed that the AA was unsure of the clinical policies specifically, but he knew the agency’s expectations was for all employees to follow the agency’s policies. Surveyor asked why the AA did not know the policy and he replied that he handled and monitored all other tasks but clinical. The Admin monitored the clinical tasks because she was a nurse. AA also stated that he is unsure why the RN#1 and RN B did not follow agency’s policies. AA stated that he did not know why the DON and ADON did not ensure that the patient’s plan of care was followed. AA stated that he did not know why RN A or RN B did not clarify the order for Patient #1. Review of agency’s updated policy manual dated 01/01/21 and titled “Administrative Policy Manual TX.5 Plan of Care” pg. 1 of 4, reads in part… “The Clinical Manager will ensure the development, implementation, and updates of the individualized plan of care.”

Assure implementation of plan of care CFR(s): 484.105(c)(5) Assuring the development, implementation, and updates of the individualized plan of care. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the clinical mangers, Director of Nurses or Alternate Director of Nurses, failed to assure the implementation and updates of the individualized plan of care in three (Patient # 1) 1 of 7 active records reviewed, in that: In one (Patient #1) of one active patient the skilled nurse failed to accurately transcribe the hospital discharge and currently taking medications correctly. Current insulin orders were transcribed incomplete. RN #1 failed to follow initial referral orders upon admission for certification period from 05/26/2025-07/24/2025 for Client#1 which included comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation, which included insulin orders. RN B failed to follow insulin orders dated 05/26/2025. The failure placed Patient # 1 at risk of a decline in health and an exacerbation of current disease processes. Findings included: Review of active Patient #1 electronic medical record (EMR) revealed a skilled nursing services with certification plan of care (POC) from 05/26/2025-07/24/2025 with primary diagnosis of Type 2 diabetes mellitus w diabetic chronic kidney disease (type 2 diabetes mellitus(T2DM) refers to high blood sugar levels, while diabetic chronic kidney disease is kidney damage caused by T2DM, Low vision right eye category 1, low vision left eye category 1 (low vision refers to chronic visual impairments that cannot be corrected with glasses, contact lenses, or medical or surgical treatment), Long term (current) use of insulin (the ongoing use of insulin in patients who require it for the management of diabetes mellitus), Type 2 diabetes w/ unspecified diabetic retinopathy without macular edema (means that a person had T2DM and is at risk of developing diabetic retinopathy without macular edema. A condition where high blood sugar levels cause damage to blood vessels in the retina. These blood vessels can swell, leak, or close, leading to changes that can affect vision), End stage renal disease (last stage of chronic kidney disease and which can be treated with dialysis or kidney transplant), and Dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. When kidneys are damaged, they are no longer able to remove wastes and excess fluid from the bloodstream efficiently). Further review of the POC revealed orders for skilled nursing (SN) once a day for 60 days, and 1-2 additional visit(s) as needed for disease process exacerbation, complications, and post-fall assessment. A. SN for comprehensive assessment each visit: 2. Current medications (review and reconcile); patient/caregiver ability to manage medication and treatment regimens. 3. Medications: dose, route, frequency, purpose, side effects, potential adverse reactions, ineffective drugs for reporting, medication regimen compliance - filling pillbox properly. B. SN to teach/train patient/caregiver where knowledge deficit noted: 10. All aspects of diabetes management, diabetic retinopathy with macular edema to include disease process, skin, foot assessments and care, signs and symptoms of hypo/hyperglycemia, diet and hydration, exercise/activity, glucometer (a medical device for determining the approximate concentration of glucose in the blood) use, preparation and administration of diabetes medications including rotation of injections sites ordered by physician. SN to administer Insulin Glargine Subcutaneous (a long-acting modified form of medical insulin)100 unit/ML, Pen 3 ML under the skin daily with 5 units. Patient unable to manage and administer medication due to poor visions, had trouble checking blood sugar, unable to tell markings on insulin syringes. Obtain fingerstick fasting blood sugar (FBS) or random blood sugar (RBS) every visit and as needed if patient unable/unwilling or reports hypo/hyperglycemia. SN to perform inspection of patient's lower extremities every visit and report any alteration in skin integrity to physician. C. SN interventions within the current certification period: 1. Medication review, reconciliation every visit. 9. SN to administer Insulin Glargine Subcutaneous 100 unit/ML, under the skin daily with 5units. Patient unable to manage and administer medication due to poor visions, had trouble checking blood sugar, unable to tell markings on insulin syringes. Obtain fingerstick FBS or RBS every visit and as needed if patient unable/unwilling or reports hypo/hyperglycemia. SN to perform inspection of patient's lower extremities every visit and report any alteration in skin integrity to physician. Record review of Patient #1’s medication profile revealed the following orders: INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS (the lowermost layer of the integumentary system). Inject 5-10units subcutaneously daily for BS 200 mg/dL subcutaneously (to inject the lowermost layer of the integumentary system) per Medical Doctor (MD) orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 05/29/2025, revealed that RN B documented that Patient #1 was administered 6 units of insulin glargine to Patient Right-Abdomen via flex pen; Blood Sugar: 198; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 05/30/2025, revealed that RN B documented that Patient #1 was administered 5 units of insulin glargine to Patient Left-Abdomen via flex pen; Blood Sugar: 154; Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 05/31/2025, revealed that RN B documented Patient #1 was administered 5 units of insulin glargine to Patient Left-Abdomen via flex pen; Blood Sugar: 121; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 06/01/2025, revealed that RN B documented Patient #1 was administered 5 units of insulin glargine to Patient Right-Abdomen via flex pen; Blood Sugar: 211; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. MAR dated 06/02/2025, revealed that RN B documented Patient #1 was administered 5 units of insulin glargine to Patient Left-Abdomen via flex pen; Blood Sugar: 156; and Comments: SN to administer insulin Glargine 5-10 units daily for BS 200 mg/dL subcutaneously per MD orders, can increase up to 17 to 20 units if BS is still above 200 mg/dL for three days and to be administered by SN every visit. Medications reviewed and reconciled. SN instructed patient to take all medications as ordered by MD. Patient needs assistance in blood glucose and blood pressure monitoring, insulin administration, medication administration due to unable to see in both eyes related to diabetic retinopathy. Record review of clinical record titled “Veterans Health Administration (VHA) Medical Documentation” dated 05/06/2025, revealed Patient #1 MD orders read in part … “Skilled Home Health Care... Procedural Overview: 1. All home health services listed below: 1A. Comprehensive evaluation for formulation of a treatment plan, to include comprehensive assessment and medication reconciliation…. MEDICATIONS… INSULIN, GLARGINE-YFGN 100UNIT/ML PEN 3ML…INJECT 5 UNITS UNDER THE SKIN DAILY FOR DIABETES. ACTIVE” Record review of RN A personnel file revealed a hire date of 07/09/2021. An agency document titled “Job Description/ Performance Evaluation- RN.” The document was signed by RN A dated 07/09/2021. A document was revealed titled “Employee Acknowledgment” was signed and dated 07/09/2021 by RN A. This document read in part... “I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.” An additional document titled “Orientation Checklist” that read in part… Section V Clinical Information… Communication and Documentation requirements was initialed and dated 07/09/2021 by RN A. Nursing clinical procedural manual was initialed and dated 07/09/2021 by RN A. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 03/31/2027. Record review of RN B personnel file revealed a date of hire for 03/28/2025. An agency document titled “Job Description/Performance Evaluation- RN.” The document was signed by RN B dated 03/28/2025. A document was revealed titled “Employee Acknowledgment” was signed and dated 03/28/2025 by RN B. This document read in part... “I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.” An additional document titled “Orientation Checklist” that read in part… Section V Clinical Information… Communication was initialed and dated 03/28/2025 by RN B. Nursing clinical procedural manual was initialed and dated 03/28/2025 by RN B. An additional document titled “Texas Board of Nursing” read in part… Board of Nursing- License Type- RN; License status- Current; and Current expiration date 12/31/2025. During a telephone interview with RN B on 06/05/2025 at 12:19 P.M. RN B indicated that he started about a couple of months ago with the agency. Stated that he had been a RN for 15 years. Stated that Patient #1 had been assigned to his care since admission. RN B reported that he performed SNV once a day. RN B indicated that his primary focus was the T2DM management. Stated that he performed random blood sugar level checks, and that he typically had to administers five to six units of the glargine long-acting insulin. Just once a day, usually in abdomen. RN B continued to state that Patient #1’s blood sugars were usually ranging from 110s to 180s; sometimes 190s. Surveyor inquired if Patient #1 had a sliding scale for her insulin or if she had orders for a specific daily dose. RN B explained that there's supposed to be a sliding scale, but Patient #1 always wanted the same 5 units. RN B stated that she didn’t want anything more than the 5 units. RN B stated that he convinced her she needed more when indicated. RN B continued to explain that usually it depended upon the nurses’ discretion; for example, if Patient #1’s blood sugar was way too high the RN could give more and continue to increase the insulin based on if it was too high over a period of couple days. Surveyor asked, “Is there a range for the blood sugar levels or how would the SN determine how much insulin to give?’ RN#2 stated that he recalls seeing an order that was if her FBS was 100 to 200, Patient #1 would get 5 to 10 units and if it's above 200 you can go 11 and above units. Surveyor asked, “How would a nurse know how much insulin to administer? When would the SN administer 5 units, 6 units, 7 units, and so on?” RN B stated that the RN must look at Patient #1 and determine if she is symptomatic. For example, if Patient #1 had symptoms and was looking like she had low blood sugar, and depending on the range of her level, then the RN decided how much to administer. The normal blood sugar for a person is 80 to 120. He stated that Patient #1 was not very compliant with her diet or medication. RN B continued to explain that basically as the SN, you have to play it by ear, and the SN would have to ask Patient #1, What did you eat? Attempt to find out if Patient #1 put another couple “extra spoonful of sugar in her tea.” Surveyor asked if RN B requested to or spoke to the doctor about Patient #1’s blood sugars or insulin orders. RN B stated that he relayed all the necessary information to the MD. RN B also stated that he sent all of Patient #1 vitals; RN B corrected his self and stated that he sent it to the agency’s office. He continued that he had not personally heard anything from the MD’s office. Surveyor asked if he knew what MD the information was sent to? RN B stated that he did not remember that information. Surveyor asked if he had ever obtained a blood pressure, that was outside of the parameters, what do you do? RN B stated that on 2 separate occasions I've given her extra medication. RN B stated that initially that Patient #1 refused to take additional medication but then when she was able to see that the medication worked for her, she took the extra medications when necessary. RN B stated that he put it all into the notes. RN B also stated that Patient #1 often refused any medications, any interventions, any visits to the VA, ER, anything. She refused everything. RN B stated that he put that in his notes and then he tried to tell her to do some stuff. For example, RN B encouraged Patient #1 to take deep breaths, relax, stop being so mad at everybody, and let her know everything will be ok. RN B stated that when he took the blood pressure again, like maybe 30-45 minutes later, it typically had improved. Surveyor: “At any time, have you ever communicated to the doctor when you got those blood pressures that were out of range?" RN B stated that he had communicated with the MD’s office regarding the blood pressure irregularities via the agency’s office. RN B stated that he notified the agency’s office, then the office sent the message to the doctor. And then usually, like by the time he gets home, he already saw the letter that it had been said because they forwarded it to him too. Surveyor asked if RN B knew what the agency’s policy was related to medication administration, medication orders, specifically order clarification, or plan of care implementation. RN B stated that he was not real sure off hand. Surveyor asked, RN B if he was aware of the potential adverse effects that medications error could have on the patient. RN B stated that the patient could become extremely ill. Interview with ADON on 06/05/2025 at 2:45 pm, ADON revealed that the agency policy was to perform a medication reconciliation and review with each comprehensive assessment which was every visit. The ADON continued that the admitting nurse used the hospital discharge orders and medications on hand to do the initial admission orders. Surveyor inquired if ADON was able to provide the surveyor with evidence of the source of the current insulin orders for Patient #1. The ADON reviewed the order and stated that she was unable to provide the source of the current insulin orders for Patient #1 because it was an incomplete order and should be clarified during the admission process. The ADON stated that the DON or ADON is ultimately responsible for ensuring that all the orders are correct in the patient’s clinical record. The ADON added that the admission and primary nurses have the initial responsibility of ensuring the order is correct. ADON stated that she was unable to say why the admission nurse RN A or the current primary nurse- RN B failed to clarify the orders. The ADON stated that the agency policy is to seek clarification of any unclear orders and can’t say why the nurses had not followed the agency’s policy. ADON also stated that all nurses were expected to follow all agency policies. Re-interview with RN B was attempted but unable to reach prior to exit. Record review of DON’s personnel file, an agency document titled, “Job Description/Performance Evaluation-Director of Nurses/ Alternate.” The box checked for the Director of Nurses indicating that this job description was for the Director of Nurses. The document was signed by the DON on 09/25/2013. Surveyor requested to interview the DON and the ADON stated that the DON remains unavailable at this time. ADON stated that it is the ADON responsibility to fill in for the DON when needed. Record review of the ADON’s personnel file, an agency document titled “Job Description/Performance Evaluation-Director of Nurses/Alternate.” The box checked for the Alternate indicating that this job description in for the Alternate Director of Nurses. The document is signed by ADON and dated 02/15/17. Interview with ADON on 06/05/2025 at 4:05 P.M. revealed that the ADON had read and understood her job description and expectations of her and the nurses that report to her. Surveyor questioned how she ensured that medication reconciliation happened with every visit. ADON stated that the DON and ADON constantly reminded the nurses to perform the medication reconciliation. ADON stated that the assigned RN who performed the admission, were reminded that it was the agency’s policy to perform medication reconciliation and to check the medications on hand. The ADON continued to say that she reminded the nurses when she knew that the patient did not have medication pill boxes. The ADON stated that her staff are encouraged to come to the office to get them to give to patients identified as needed one. The VA patients usually would ask for one. ADON stated again that she did not know RN A or RN B did not follow the agency’s clinical policies. Interview with AA on 06052025 at 4:48 P.M. revealed that the AA was unsure of the clinical policies specifically, but he knew the agency’s expectations was for all employees to follow the agency’s policies. Surveyor asked why the AA did not know the policy and he replied that he handled and monitored all other tasks but clinical. The Admin monitored the clinical tasks because she was a nurse. AA also stated that he is unsure why the RN#1 and RN B did not follow agency’s policies. AA stated that he did not know why the DON and ADON did not ensure that the patient’s plan of care was followed. AA stated that he did not know why RN A or RN B did not clarify the order for Patient #1. Review of agency’s updated policy manual dated 01/01/21 and titled “Administrative Policy Manual TX.5 Plan of Care” pg. 1 of 4, reads in part… “The Clinical Manager will ensure the development, implementation, and updates of the individualized plan of care.” No further information was provided prior to the end of the survey.