Every finding on record at Comprehensive Health Care Services LLC

The following reflects the findings of the California Department of Public Health during a Recertification Survey. Representing the Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID # 25046, RN Health Facilities Evaluator Nurse, Surveyor ID # 44186, RN Number of unduplicated admissions for the past 12 months: 46 Active patients: 25 Sample Size - 7 Patients Home Visits - 3

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to conduct an initial assessment within 48 hours of the referral, for two of 7 sampled patients (Patients 2 and 3). This failure had the potential to result in a delay in the necessary treatment and could lead to a loss of well-being. Findings: a. A review of Patient 2's clinical record indicated a Start of Care (SOC) date (SOC) of 1/11/2023, with a diagnosis that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), heart failure (a condition when your heart doesn't pump enough blood for your body's needs), major depressive disorder (a mental health disorder characterized by a persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Patient 2’s clinical record indicated a signed physician’s order for the HHA to admit Patient 2 and send a registered nurse for evaluation and assessment and to assess the needs for other disciplines. The referral order was dated 1/08/2023. b. A review of Patient 3's clinical record indicated a SOC of 10/17/2022, with a diagnosis that included Alzheimer’s disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), dementia (a brain disease or injury marked by memory disorders, personality changes, and impaired reasoning), and cystitis (inflammation of the bladder, usually caused by a bladder infection). A review of Patient 3’s clinical record indicated a signed physician’s order for the HHA to admit the patient and send a registered nurse for an evaluation and assessment and to assess the needs for other disciplines. The referral order was dated 10/13/2022. On 2/17/2023, at 12:00 p.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), the DPCSD confirmed there was a delay in performing the initial SOC assessment for Patient 2 and Patient 3, and a physician order to delay the SOC had not been obtained prior to SOC. A review of the agency’s policy and procedure titled “Initial Assessments/Comprehensive Assessments,” revised February 2021, indicated each patient admitted by the agency will have appropriate initial assessments performed and documented. A RN (registered nurse), PT (physical therapist) or SLP (speech language pathologist) must conduct the initial assessment visit within 48 hours of the referral, within 48 hours of the patient’s return home, or on the physician/practitioner-ordered start of care date.

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 (HHA) staff failed to review all medications compared with the medication profile and clarify and follow up on the discrepancy with the physician for two of seven sampled patients (Patient 4, 5). This deficient practice had the potential to place the patients at risk for medication errors. a. A review of Patient 4's plan of care (POC) for the certification period 12/28/2022 to 2/25/2023, indicated a Start of Care (SOC) date of 12/28/2022, with diagnoses that included hypertensive heart disease, atrial fibrillation, and bilateral osteoarthritis. The skilled nurse (SN) was to visit Patient 4 twice a week for two weeks, then once a week for seven weeks. The SN was to perform an observation and an assessment every visit for vital signs and all body systems and check compliance to prescribed diet, medication and activity. The SN was to teach and instruct the patient and primary caregiver (PCG) regarding any new or changed medication regimen as to indication, dosage, frequency/schedule, interactions, common and reportable side effects. On 2/15/2023, at 2:15 p.m., during a home visit at Patient 4’s house with the Director of Patient Care Services Designee (DPCSD), Patient 4 was observed alert and oriented, able to communicate well, and was sitting in a chair. Primary Caregiver 1 (PCG 1) was next to the patient. At 2:30 p.m., during a review of Patient 4's current medications compared with the medication profile provided by the agency, it was noticed Patient 4 had a bottle of Amlodipine/Valsartan (10-160 mg) while the medication profile indicated the patient was to have Amlodipine/Valsartan (5-320 mg). During an interview with PCG 1, she stated the Nurse Practitioner (NP) had discontinued Amlodipine/Valsartan (5-320 mg) and ordered Amlodipine/Valsartan (10-160 mg) two weeks ago. During an interview with the DPCSP at the same time, she stated the medication profile should have been updated after clarification with the physician. b. A review of Patient 5's plan of care (POC) for the certification period 1/17/2023 to 3/17/2023, indicated a Start of Care (SOC) date of 7/21/2022, with diagnoses that included type 2 diabetes Mellitus (DM - A chronic condition that affects the way the body processes blood sugar) and dementia. The skilled nurse (SN) was to visit the patient once a week for nine weeks, and home health aide visit was twice a week for nine weeks. Patient 5 was certified for comprehensive skilled nursing assessment, observation, and evaluation of compliance to prescribed medication/diet regimen. The SN was to teach or instruct the patient and primary caregiver (PCG) regarding any new/changed medication regimen as to indication, dosage, frequency/schedule, interactions, common and reportable side effects. The POC indicated the physician ordered Rivastigmine 4.6 mg/day transdermal patch to be applied once daily. On 2/16/2023, at 11:20 a.m., during a home visit at Patient 5’s house with Registered Nurse 2 (RN 2), Patient 5 was observed lying in a hospital bed with eyes closed and not able to communicate. Family member 3 (FM 3) was next to the patient. At 11:55 a.m., during a review of Patient 5's current medications compared with the medication profile provided by the agency, it was noticed Patient 5 did not have a Rivastigmine 4.6 mg patch at home. During an interview with FM 3, she stated they ran out of Rivastigmine 4.6 mg patch one month ago and needed a prescription. During an interview with RN 2 at 12:15 p.m., She stated the SN should have followed up with the physician regarding the Rivastigmine 4.6 mg patch. A review of the agency’s policy titled “Medication Orders” revised in February 2021 indicated the medication profile will be updated. A review of the agency’s policy titled “Medication Labels” revised March 2018 indicated the agency staff will review the patients medication at the time of admission and on an ongoing basis.

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 interview and record review, the agency staff failed to follow the written plan of care (POC) established by the physician for two of seven sampled patients (Patients 1 and 6). a. For Patient 1, patient’s oxygen saturation (O2 sat, the amount of oxygen circulating in your blood) was not assessed. b. For Patient 6, the patient's pain assessment was incomplete. These deficient practices had the potential to result in a delay of healthcare response, treatment, and intervention that could result in complications to an already compromised patient's health status. b. A review of Patient 6's clinical record disclosed a start of care dated 10/22/2022, with diagnoses which included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), non-pressure chronic ulcer of right ankle, and plantar fascial fibromatosis. The POC for the certification period from 12/21/2022 through 2/18/2023, included order for the skilled nurse (SN) to visit the patient once a week for 9 weeks, and the physical therapy visit two times a week for 4 weeks. Patient 6 was certified for comprehensive skilled nursing assessment, observation, and evaluation of pain. The POC included orders for discipline to implement pain relief measures and its effectiveness in pain scale from zero to 10. The PT was to evaluate and follow up visit for therapeutic exercises and pain management to alleviate pain. A review of the “Nursing Progress Note” from 12/23/2022 to 1/20/2023 indicated Patient 6 had pain intensity of 2-4 on a pain scale from zero to ten (2-4/10) on the bilateral extremities. Treatment included non-pharmaceutical interventions and medication. However, there was no indication whether the pain level was before or after intervention. A review of the Physical Therapy Visit note dated 12/21/2022, 1/30/2023, indicated the space for pain assessment were blank. There was no documented evidence the PT had performed pain assessment. A review of the Physical Therapy Visit note dated 12/2/2022, 1/11/2023, 1/16/2023, 1/18/2023, 1/23/2023, and 1/25/2023, indicated the pain was marked as “same” “improved” with relief measures of “Range of motion (ROM) stretch, massage”. However, there was no pain level assessment During an interview with the Director of Patient Care Services Designee (DPCSD) on 2/17/2023, at 11:30 a.m., she was not able to answer whether the pain level from 12/23/2022 to 1/20/2023 was before or after intervention. The DPCSD stated the SN should have assessed pain level before and after intervention/medication. The DPCSD stated the physical therapist also should have assessed the pain level on above days to ensure the intervention was effective. A review of the agency's policy of "Pain Assessment and Reassessment" revised in January 2020 indicated appropriate agency staff will assess and reassess the patient’s pain. It indicated when a patient’s pain is not relieved, the nurse or therapist will intervene appropriately. Such interventions may include notification of patient’s physician and patient education regarding alternative pain relief measures such as relaxation therapy and music therapy. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 1/30/2023, with diagnosis which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and anemia (a condition in which the body lacks enough healthy red blood cells to carry adequate oxygen to your body's tissues). A review of Patient 1's “Home Health Certification and Plan of Care (POC)”, for certification period from 1/30/2023 to 3/30/2023, included an order for the skilled nurse (SN) to visit once a week for nine weeks. The POC indicated for the SN to assess all body systems and perform every visit V/S (vital signs, measures the body's basic functions. These include your temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation). A review of Patient 1’s Nursing Progress Note, indicated that the patient’s oxygen saturation was not documented on 2/08/2023. On 2/17/2023, at 12:00 p.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), the DPCSD confirmed O2 sat was not assessed and documented during a nurse visit on 2/08/2023. A review of the agency’s policy and procedure titled “Plan of Care – CMS #485 and Physician/Practitioners Orders”, revised February 2021, indicated skilled nursing and other home health services will be in accordance with a plan of care based on the patient’s diagnosis and assessment of immediate and long-range needs and resources.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview, and record review, the home health agency (HHA) failed to ensure the plan of care (POC- statement of care, interventions, and goals) was developed and implemented for one of 7 sampled patients (Patient 1). There was no documented evidence that the plan of care included pain management, assessing the patient's pain, location, duration, severity (rating scale), alleviating factors, current treatment, and response to treatment. This deficient practice had the potential to negatively affect the patient's physical wellbeing and affect the delivery of necessary care and services. Findings: A review of Patient 1's clinical record indicated a Start of Care date (SOC) of 1/30/2023, with a diagnosis which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and anemia (a condition in which the body lacks enough healthy red blood cells to carry adequate oxygen to your body's tissues). A review of Patient 1's “Home Health Certification and Plan of Care (POC)”, for the certification period 1/30/2023 to 3/30/2023, included an order for the skilled nurse (SN) to visit Patient 1 once a week for nine weeks, to assess all body systems, assess/monitor for medication effectiveness, and perform vital signs on every visit. There was no documented evidence that the plan of care included pain management, assessing the patient's pain, location, duration, severity (rating scale), alleviating factors, and response to treatment. A review of Patient 1's clinical records dated 2/03/2023, documented Patient 1 experienced back pain which was described and assessed at a level of 4/10 (on a pain scale rated 0 [no pain] to 10 [worst pain]). However, there was no documentation regarding pain management, intervention and evaluation for any treatment provided. On 2/17/2023, at 12:00 p.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), when informed of the findings, the DPCSD agreed there was no documentation which included pain management. A review of the agency’s policy and procedure titled “Plan of Care – CMS #485 and Physician/Practitioners Orders”, revised February 2021, indicated each patient must received an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet and identify the patient-specific needs, measurable outcomes, and goals.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the home health agency (HHA) failed to ensure the Plan of Care was revised to include Patient 4's current parameter of blood pressure medication administration after clarifying with the physician for one of seven (7) sampled patients (Patient 4). This failure had a potential to result in miscommunication among health care providers and the primary caregiver for Patient 4's blood pressure management. A review of Patient 4's plan of care (POC) for the certification period 12/28/2022 to 2/25/2023, indicated a Start of Care (SOC) date of 12/28/2022, with diagnoses that included hypertensive heart disease, atrial fibrillation, and bilateral osteoarthritis. The skilled nurse (SN) was to visit the patient twice a week for two weeks, then once a week for seven weeks. The SN was to perform observation and assessment every visit to check vital signs and all body systems and compliance to prescribed diet, medication and activity. The SN was to teach or instruct the patient and primary caregiver (PCG) regarding any new or changed medication regimen as to indication, dosage, frequency schedule, interactions, common and reportable side effects. The POC included the physician’s order for Amlodipine/Valsartan (5-320 mg) one tablet by mouth once daily. On 2/15/2023, at 2:15 p.m., during a home visit at Patient 4’s house with the Director of Patient Care Services Designee (DPCSD), Patient 4 was observed alert and oriented, able to communicate well, and was sitting in a chair. Primary Caregiver 1 (PCG 1) was next to the patient. At 2:30 p.m., during a review of Patient 4's current medications compared with the medication profile provided by the agency, it was noticed Patient 4 had a bottle of Amlodipine/Valsartan (10-160 mg) while the medication profile indicated the patient was to have Amlodipine/Valsartan (5-320 mg). During an interview with PCG 1, she stated the Nurse Practitioner (NP) had discontinued Amlodipine/Valsartan (5-320 mg) and ordered Amlodipine/Valsartan (10-160 mg) two weeks ago. PCG 1 further stated she did not give Amlodipine/Valsartan (10-160 mg) that day because one time, the patient almost fell after the patient took the blood pressure medication. PCG 1 stated when the patient’s systolic blood pressure is more than 150 mmHg, she waits and take the blood pressure again. When the systolic blood pressure is still more than 150 mmHg, she administers Amlodipine/Valsartan (10-160 mg). PCG 1 stated if the patient’s systolic blood pressure is less than 140 mmHg medication, she had not given Amlodipine/Valsartan (10-160 mg) to the patient for two weeks as directed by the NP. PCG 1 stated she told the agency’s nurse about it. At 2:50 p.m., during an interview with Family member 2 (FM 2) she stated the parameter to hold Amlodipine/Valsartan (10-160 mg) was when the blood pressure was less than 140/74 mmHg. A review of Patient 4’s clinical record indicated there was no documented evidence the agency’s staff had communicate with the physician/NP about the new direction/parameter, and had revised the POC. On 2/17/2023, at 11:30 a.m., during an interview with the Director of Patient Care Services Designee (DPCSD), she was not able to provide the documented evidence the agency’s staff had communicated with the physician/NP about the new direction/parameter and had revised the POC. The DPCSD stated the agency’s staff should have communicated with the physician for the parameter and revised the POC. A review of the agency’s policy titled “Care Planning Process” revised in February 2021 indicated the patient care plan for therapy services will be revised as problems are identified. Review and revision will be ongoing with each home visit and will be based on the patient’s health status, environment and relevant baseline data from assessments to determine current needs, problems, interventions and goals. The nursing Care Plan update form may be utilized to update the care plan between certification and re-certifications to document modifications. A review of the agency’s policy titled “Coordination of Patient Care” revised in February 2021 indicated the agency must assure communication with all physician/practitioners involved in the plan of care.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure a patient’s glucometer was control-solution tested and calibrated for one of seven (7) sampled patients (Patient 5). This deficient practice had the potential to result in an incorrect blood sugar level result and place the patient at risk of hyperglycemia (an excess of glucose in the bloodstream)/hypoglycemia (deficiency of glucose in the bloodstream). A review of Patient 5's plan of care (POC) for the certification period 1/17/2023 to 3/17/2023, indicated a Start of Care (SOC) date of 7/21/2022, with a diagnoses that included type 2 Diabetes Mellitus (DM - A chronic condition that affects the way the body processes blood sugar) and dementia. The skilled nurse (SN) was to visit the patient once a week for nine weeks, and the home health aide was to visit twice a week for nine weeks. Patient 5 was certified for a comprehensive skilled nursing assessment, observation, and evaluation of compliance to prescribed medications and diet regimen. The SN was to assess Patient 5's blood sugar level every visit via fingerstick method. The SN was to teach/validate the patient/primary caregiver (PCG)’s ability to competently and independently perform blood sugar monitoring via fingerstick and glucometer calibration and understanding of the hypoglycemia/hyperglycemia protocol. On 2/16/2023, at 11:20 a.m., during a home visit at Patient 5’s house with Registered Nurse 2 (RN 2), Patient 5 was observed lying in a hospital bed with eyes closed and not able to communicate. Family member 3 (FM 3) was next to the patient. At 12:10 p.m., FM 3 brought Glucometer 1 and stated Patient 5 had been using Glucometer 1 for two-three years. When asked, FM 3 stated Glucometer 1 had not been calibrated from the beginning and she did not even know where the control solution was. During an interview with RN 2 at the same time, she stated Glucometer 1 should have been calibrated at the beginning and whenever a new strip bottle is opened. During an interview with the Director of Patient Care Services Designee (DPCSD) on 2/17/2023, at 11:30 a.m., she was not able to provide the documented evidence the agency’s nursing staff had instructed the patient and caregiver regarding glucometer calibration. The DPCSD stated the nursing staff should have instructed the patient/PCG about the glucometer calibration. A review of the Owner’s booklet for Glucometer 1 indicated a Control Test for practice is recommended before using it for the first time to test blood. It indicated the Control Tests should be performed as follows: 1. For practice to ensure your test technique is good 2. Occasionally as you use a vial of test strip 3. When opening a new vial of test strips 4. If results seem unusually high or low 5. If a vial has been left opened or exposed to extreme Heat or cold, or humidity 6. Whenever a check on performance of the system is needed 7. If meter damage is suspected (meter was dropped, crushed, wet, etc.)

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to provide written information of the medications to the patient and caregiver including the side effects of the medications the patients were taking. This deficient practice resulted in the medication information not being available to the patients and caregiver when needed. a. A review of Patient 4's plan of care (POC) for the certification period 12/28/2022 to 2/25/2023, indicated Start of Care (SOC) dated 12/28/2022, with diagnoses that included hypertensive heart disease, atrial fibrillation, and bilateral osteoarthritis. The skilled nurse (SN) was to visit Patient 4 twice a week for two weeks, then once a week for seven weeks. The SN was to perform observation and assessment every visit for vital signs and all body systems and compliance to prescribed diet, medication and activity. The SN was to teach or instruct the patient and primary caregiver (PCG) regarding any new or changed medication regimen as to indication, dosage, frequency and schedule, interactions, common and reportable side effects. On 2/15/2023, at 2:15 p.m., during a home visit at Patient 4’s house with the Director of Patient Care Services Designee (DPCSD), Patient 4 was observed alert and oriented, able to communicate well, and was sitting in a chair. Primary Caregiver 1 (PCG 1) was next to the patient. At 2:30 p.m., a review of Patient 4's medication profile provided by the agency, indicated there was no side effects included in it. During an interview with PCG 1, at the same time, she stated she did not know the classification or side effect of Patient 4’s medications. b. A review of Patient 5's plan of care (POC) for the certification period 1/17/2023 to 3/17/2023, indicated a Start of Care (SOC) date of 7/21/2022, with diagnoses that included type 2 diabetes mellitus (DM - A chronic condition that affects the way the body processes blood sugar) and dementia. The skilled nurse (SN) was to visit the patient once a week for nine weeks, and the home health aide was to visit twice a week for nine weeks. Patient 5 was certified for comprehensive skilled nursing assessment, observation, and evaluation of compliance to prescribed medication and diet regimen. The SN was to teach or instruct the patient and primary caregiver (PCG) regarding any new or changed medication regimen as to indication, dosage, frequency and schedule, interactions, common and reportable side effects. The POC indicated the physician’s ordered Rivastigmine 4.6 mg/day transdermal patch once daily. On 2/16/2023, at 11:20 a.m., during a home visit at Patient 5’s house with Registered Nurse 2 (RN 2), Patient 5 was observed lying in a hospital bed with eyes closed and not able to communicate. Family member 3 (FM 3) was next to the patient. At 11:55 a.m., during a review of Patient 5's medication profile provided by the agency, there were no side effects included in it. During an interview with FM 3 at the same time, she stated she did not know the classification or side effect of Patient 5’s medications. When asked, FM 3 stated she was not provided the written instruction about Patient 5’s medications including action and side effects of the medication by the agency. During an interview with the Director of Patient Care Services Designee (DPCSD) on 2/17/2023, at 11:30 a.m., she was not able to locate the documented evidence that written instruction including the side effects of Patient 5’s medications, was provided to Patient 4/PCG 1 and Patient 5/FM 3. The DPCSD stated the written instruction of medication should have been provided to the patients/PCG. A review of the agency’s policy titled “Medication Profile” revised in March 2018 indicated the RN and Licensed Practical Nurse (LPN) review the medications with the patient on an ongoing basis to ensure the understanding of medication use. The review will include side effects, storage and administration of all medications. The written information regarding the patient’s medication regimen is provided to the patient and/or caregiver and based on the results of the medication review conducted at start of care and on an ongoing basis.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency staff failed to follow the plan of care (POC) for one of seven (7) sampled patients (Patient 1). The visiting nurse failed to provide patient teaching regarding insulin management. This failure had the potential to result in improper administration of insulin and cause harm and affect the patient's progress in reaching their goals. A review of Patient 1's clinical record indicated a Start of Care date (SOC) of 1/30/2023, with diagnosis that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and anemia (a condition in which the body lacks enough healthy red blood cells to carry adequate oxygen to your body's tissues). A review of Patient 1's “Home Health Certification and Plan of Care (POC)”, for the certification period 1/30/2023 to 3/30/2023, included an order for the skilled nurse (SN) to visit Patient 1 once a week for nine weeks. The POC indicated for the SN to perform blood sugar (BS) monitoring every visit and to assess and/or monitor for medication effectiveness, possible adverse effects, and duplication. The POC also indicated for the SN to teach and/or validate patient or patient caregiver understanding on safe use of narcotics or high-risk medication, and medication regimen and medication administration. A review of Patient 1’s “Medication Profile”, indicated the patient was on Novolin 70/30 (a combination medicine used to improve blood sugar control in adults with diabetes mellitus) inject 20 units subcutaneously every morning and five units in the evening. During a home visit at Patient 1's residence with the Registered Nurse (RN 1), on 2/16/2023 at 2:35 p.m., Patient 1 was observed awake, alert and ambulatory with a steady gait. During a review of Patient 1's medications with RN 1, it was observed an open/used Novolin 70/30 insulin vial (bottle) was not labeled and dated when it was first used. During a concurrent interview with the patient’s caregiver (FM 1), she stated she administers Novolin 70/30 insulin to Patient 1 once in the morning and then one time at night as ordered by the physician. She stated she was not aware the insulin bottle will expire in 42 days from the day it was first opened or used. FM 1 stated she was not sure if the visiting nurse gave instructions to label and date the insulin bottle when it was first used. A further review of Patient 1's Skilled Nursing Visit notes and assessment, indicated no documented evidence the visiting nurse provided a detailed instruction to the patient/patient’s caregiver regarding insulin management. On 2/17/2023, at 12:00 p.m., during a concurrent interview and record review with the Director of Patient Care Services Designee (DPCSD), the DPCSD stated the insulin medications should be dated once opened or first used. She also stated the patient should have been provided patient teaching on insulin management as per the plan of care. A review of the agency’s policy and procedure titled “Plan for Patient/Family Education”, revised March 2018, indicated the agency will educate and train the patient/family according to the needs assessed by the agency staff and as appropriate to the required services. All patient/family education, the perceived comprehension, ability to demonstrate a taught skill and verbal recall will be documented in the patient’s medical record.