Every finding on record at Dch Health Care Authority

A recertification survey was conducted on 7/15/25 to 7/17/25 and DCH Home Health Care Agency was found to be in substantial compliance with the Conditions of Participation for Emergency Preparedness.

A recertification survey was conducted on 7/15/25 to 7/17/25 at DCH Home Health Care Agency. Standard level deficiencies were cited and will require a Plan of Correction.

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 review of medical records (MR), observations, agency policy and procedure, and interviews, it was determined the agency failed to keep the medication profile current. This policy did affect six out of seven home visits (HV) including HV # 1, HV # 7, HV # 4, HV # 5, HV # 2, and HV # 6, and had the potential to affect all persons served by the agency. Findings include: Agency Policy: Medication Assessment and Reconciliation Policy Number: None Reviewed Date: September 2022 Policy: Assessment of the patient's medications and reconciliation of physician's orders with medications available in the home will be done on every nurse visit to the home by the Registered Nurse (RN) or Licensed Practical Nurse (LPN). Other disciplines visiting the patient such as the Physical Therapist (PT), Licensed Physical Therapy Assistant) (LPTA), Occupational Therapist (OT), Certified Occupational Therapy Assistant (COTA), Speech Therapist (ST), Medical Social Worker (MSW), Home Health Aide (HHA) will ask the patient if there has been a change in their medications and if the response is yes, the primary care manager (PCM) will be notified. In the event of a therapy only case, the therapy manager will assume responsibility for medication assessment and reconciliation in collaboration with the clinical manager. Purpose: To ensure the medication list maintained within the patient's medical record is up to date and current with medications in the home. To ensure the patient is taking the correct medications at the correct times as ordered by the physician. Procedure: The Skilled Nurse (SN)/ care manager (CM) will take actions to assure accurate reconciliation of patient medications by following these steps: A. The SN/CM is to review all medications in the home on every visit to ensure patients are taking medication as prescribed and the patient's medication profile is always accurate and up to date... 5. HV # 2 was admitted to the agency on 7/3/25 with diagnoses including Acute Kidney Failure, Unspecified and Low Back Pain, Unspecified. Review of the HHCPOC for the certification period 7/3/25 to 8/31/25 revealed orders for the SN to visit once a week for one week, two times a week for one week and once a week for three weeks. Further review of HV # 2's MR revealed orders for PT evaluation once a week for one week effective 7/13/25. A HV was conducted on 7/15/25 at 1:40 PM to observe care provided by EI # 9, PT. EI # 10, Patient Care PCM, was also present on the visit. During the HV, HV # 2's CMR was compared to the medications the patient is currently taking. The following medication was observed in the home but not on the medication profile: a. Humalog Kwikpen 100 U (units) with a fill date of 2/6/24. HV # 2 stated he/she still takes the medication. An interview was conducted on 7/17/25 at 11:25 AM with EI # 2, who confirmed staff failed to keep the medication profile current. 6. HV # 6 was admitted to the agency on 4/26/25 with diagnoses including Non-Pressure Chronic Ulcer of Other Part of Right Lower Leg with Fat Layer Exposed and Encounter for Change and Removal of Non-Surgical Wound Dressing. A review of the HHCPOC for the certification period 6/25/25 to 8/23/25 revealed orders for the SN to visit two times a week for two weeks then once a week for seven weeks. A HV was conducted on 7/16/25 at 8:36 AM to observe care provided by EI # 5, RN. EI # 6, RN, Intake Coordinator was also present on the visit. During the HV, HV # 6's CMR was compared to the medications the patient was currently taking. The following medication was observed in the home but not on the medication profile: a. Ropinirole HCL (Hydrochloride) 0.5 mg tablets, take two tablets at 5:00 PM, and one tablet at HS (bedtime), with a fill date of 5/8/25. HV # 6 stated he/she has taken the medication for restless legs for years. An interview was conducted on 7/17/25 at 11:33 AM with EI # 2, who confirmed staff failed to keep the medication profile current. 3. HV # 4 was admitted to the agency on 6/8/25 with a diagnosis of Wedge Compression Fracture of T11-T12 Vertebra, Subsequent Encounter for Fracture with Routine Healing, and certified for care 6/8/25 to 8/6/25. Review of the HHCPOC for the certification period 6/8/25 to 8/6/25 revealed orders for the SN to visit three times a week for one week, two times a week for one week and once a week for seven weeks. The PT was ordered to visit two times a week for three weeks and once a week for two weeks. The OT was ordered to visit once a week for four weeks. A HV was conducted on 7/15/25 at 3:17 PM to observe care provided by EI # 4, ST. EI # 6, RN was also present during the visit. During the visit, the CMR dated 7/15/25 was compared to the medications found in the home. The following discrepancy was observed: a. Over the Counter Vita Fusion Power C, take three gummies daily was in the home and not on the medicine list. HV # 4, stated, “I have been taking one gummy daily for about three months.” An interview was conducted on 7/17/25 at 11:31 AM with EI # 8, Home Health Assistant Director, who confirmed the staff failed to keep the medication profile current. 4. HV # 5 was admitted to the agency on 7/12/25 with a diagnosis of Cerebral Infarction Unspecified and certified for care 7/12/25 to 9/9/25. Review of the HHCPOC for the certification period 7/12/25 to 9/9/25 revealed orders for the SN to visit one time a week for one week, two times a week for two weeks and two times every three weeks for three weeks. A HV was conducted on 7/15/25 at 12:29 PM to observe care provided by EI # 3, OT. EI # 6, RN was also present during the visit. During the visit, the CMR dated 7/15/25 was compared to the medications observed in the home. The following discrepancy was observed: a. Megestrol 40 milligram tablet, take one tab twice daily for appetite with fill date 7/5/25 was in the home and not on the medicine list. HV # 5’s caregiver, reported the patient had been taking the medication since the fill date. An interview was conducted on 7/17/25 at 11:37 AM with EI # 8, Home Health Assistant Director, who confirmed the staff failed to keep the medication profile current. 1. HV # 1 was admitted to the agency on 6/25/25 with a diagnosis of Type 2 Diabetes Mellitus with Hypoglycemia, Without Coma. Review of the Home Health Certification and Plan of Care (HHCPOC) for the Certification Period 6/25/25 to 8/23/25 revealed an order for SN Visits once weekly for six weeks. A HV was conducted on 7/15/25 at 11:25 AM to observe care provided by EI # 8, Home Health Aide (HHA). EI # 1, Home Health Director, was present for the HV. During the visit, the Client Medication Report (CMR) dated 7/15/25 was compared to the medications observed in the home. The following discrepancies were observed: a. Januvia 50 milligram (mg) tablet, one tablet two times daily with a start date of 7/2/25, was listed on the CMR. The patient's spouse stated HV # 1 had not taken the medication since released from the hospital on 6/23/25. b. Metformin 500 mg tablet, one tablet two times daily with a start date of 7/2/25, was listed on the CMR. The patient's spouse stated HV # 1 had not taken the medication since released from the hospital on 6/23/25. An interview was conducted on 7/17/25 at 11:25 AM with EI # 2, Assistant Home Health Director, who confirmed staff failed to keep the medication profile current. 2. HV # 7 was admitted to the agency on 10/31/24 with a diagnosis of Other Forms of Systemic Lupus Erythematosus. Review of the HHCPOC dated 6/28/25 to 8/26/25 revealed SN visits were ordered once weekly for eight weeks. A HV was conducted on 7/16/25 at 10: 05 AM to observe care provided by EI # 7, RN. EI # 1 was present on the HV. During the visit, the CMR dated 7/15/25 was compared to the medications observed in the home. a. Meloxicam 15 mg, one tablet daily, with a fill date of 3/27/25, was observed in the home and was not listed on the CMR. HV # 7 stated they take the medication daily. b. Lasix 20 mg, one tablet daily, with a fill date of 5/13/25, was observed in the home and was not listed on the CMR. The patient stated they last took the medication on Sunday 7/13/25. c. Prednisone 5 mg, three tablets daily, with a fill date of 5/13/25, was observed in the home and was not listed on the CMR. The patient stated they take the medication daily. d. Methenamine One Gram tablet, one tablet two times daily, with a fill date of 6/15/25, was observed in the home and was not listed on the CMR. The patient stated they take the medication every day to prevent recurrent Urinary Tract Infections.. e. Duloxetine 30 mg, one tablet daily, with a fill date of 6/19/25, was observed in the home and was not listed on the CMR. HV # 7 stated they last took the medication on 7/15/25. f. Tizanidine 4 mg, one tablet daily as needed for muscle spasms, was observed in the home and was not listed on the CMR. g. Clindamycin 300 mg, one tablet twice daily for 14 days, with a fill date of 7/4/25, was observed in the home and was not listed on the CMR. The patient stated they had been taking the medication since 7/7/25. h. Hydroxychloroquine 200 mg, two tablets twice daily, with a fill date of 5/17/25 was observed in the home. The medication was listed on the CMR with instructions to take two tablets at bedtime. i. Pregabalin 200 mg, one capsule three times daily, with a fill date of 6/22/25 was observed in the home. The medication was listed on the CMR with instructions to take one capsule twice daily. j. Pregabalin 150 mg, one capsule by mouth before lunch, was listed on the CMR. The patient stated the medication was discontinued on 6/22/25. An interview was conducted on 7/17/25 at 11:20 AM with EI # 2, who confirmed staff failed to keep the medication profile current.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on observations, review of medical records (MR), agency policy and procedure, and staff interviews, it was determined the facility failed to ensure: 1. Staff obtained and adhered to physician's orders for wound care. 2. Staff followed the physician's order for gastrostomy tube care. This affected Home Visit (HV) # 7, in one of seven MRs reviewed with wound care orders and MR # 3 in one of one MRs reviewed with a gastrostomy tube and had the potential to negatively affect all patients served by the agency. Findings include: Agency Policy: Physician/Non-Physician Provider Order/Progress and Goal Update Revised Date: 12/21 Policy: Orders received from the physician or non-physician provider are entered into the patient's Electronic Medical Record (EMR). All orders are reviewed prior to care to insure that care is being provided according to the most recent order. The physician or non-physician provider will serve as the ongoing revision of the patient's plan of care (POC). No care will be provided without a physician's or non-physician provider order. Purpose: To update the POC with all orders received from the physician or non-physician provider. To provide the physician and all members of the patient care team with documentation of new or changed problems, new or changed orders, and the expected outcome. Procedure: .a. ...All orders are reviewed for accuracy prior to administering medications, treatments, or delivering care. Special Points: a. Patients are evaluated and reassessed based on the care plan and established goals. Staff assesses patient for progress toward goals and contacts physician or non-physician provider to revise plans and goals for the patient as appropriate. Agency Policy: Enteral Tube Feeding, Intermittent, Gastrostomy, and Jejunostomy Revision Date: 11/18/24 ...Implementation: ...Verify enteral tube placement using at least two of the following methods: Observe for a change in the external length or the incremental marking on the tube at the exit site to determine whether the tube has migrated. Observe for a change in the volume of aspirate from the external tube... Review routine chest and abdominal x-ray reports. Aspirate the enteral tube contents and inspect the visual characteristics of the tube aspirate... 1. HV # 7 was admitted to the agency on 10/31/24 with a primary diagnosis of Other Forms of Systemic Lupus Erythematosus. A HV was conducted on 7/16/25 at 10:05 AM with EI # 7, Registered Nurse, who provided wound care for HV # 7. EI # 1, Home Health Director, was present on the visit. A review of the Home Health Certification and Plan of Care (HHCPOC) for the Certification Period dated 6/28/25 to 8/26/25 revealed orders for the Skilled Nurse (SN) to provide wound care to wound # 2, right fourth finger, SLE Vasculitis Ulcer, and wound # 8, right distal forearm burn. EI # 7 performed wound care to wound # 2, right fourth finger, and an unidentified wound on the left great toe. There was no wound care orders for the wound care on the left great toe. An interview was conducted on 7/17/25 at 11:20 AM with EI # 2, Assistant Home Health Director, who confirmed staff failed to obtain and adhere to wound care orders. 2. MR # 3 was admitted to the agency on 6/14/25 with diagnoses that included fracture of orbital floor, right side and Maxillary Fracture, right side, following a gun shot wound. Review of the HHCPOC revealed orders for the SN to visit once weekly for two weeks, then twice weekly for one week, then once weekly for three weeks. Further review of the HHCPOC revealed orders for the SN for preparation, administration, and instruction of gastrostomy feeding... Check tube placement and residual prior to administering feedings... Caregiver to perform care when SN is not scheduled to visit. Review of seven of seven SN Visit Reports dated 6/14/25, 6/20/25, 6/24/25, 6/27/25, 7/1/25, 7/8/25, and 7/16/25 revealed no documentation the SN checked the gastrostomy tube placement or the residual. An interview was conducted on 7/17/25 at 11:15 AM with EI # 2, who confirmed staff failed to follow the physician's order for gastrostomy tube care.

Based on the recertification survey conducted on 9/15/2022, DCH Home Health Care Agency was found to be in substantial compliance with the standards for Emergency Preparedness.

A recertification survey was conducted on 9/13/22 to 9/15/22, with standard level deficiencies cited.

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 review of medical records (MR), policy and procedure, observations, and interviews, it was determined the agency failed to ensure staff updated the medication profile. This affected three of seven Home Visits (HV) conducted, including HV # 2, HV # 3, HV # 5, and had the potential to affect all patients admitted to the agency. Findings include: Agency Policy: Medication Assessment and Reconciliation Policy number: None listed Date revised: August 2021 I. Policy: Assessment of the patient's medications and reconciliation of physician's orders with medications available in the home will be done on every nurse visit to the home by the RN (Registered Nurse) or LPN (Licensed Practical Nurse). Other disciplines visiting the patient such as the PT (Physical Therapist)... OT (Occupational Therapist)... will ask the patient if there has been a change in their medications... If (in) the event of a therapy only case, the therapy care manager will assume responsibility for medication assessment and reconciliation in collaboration with clinical manager. Purpose: To insure (ensure) that the medication list maintained within the patient's medical record is up to date and current with medications in the home. To insure (ensure) the patient is taking the correct medications at the correct times as ordered by the physician. II. Procedure: The SN (Skilled Nurse)/ care manager will take actions to assure accurate reconciliation of patient medications by following these steps: A. The SN/ care manager is to review all medications in the home on every visit to ensure that patients are taking their medication as prescribed and that the patient's medication profile is always accurate and up to date. ...C. When discrepancies are found with any of the elements noted in II-B, the physician will be contacted to reconcile medications and ensure the patient is receiving the correct medications. 3. HV # 5 was admitted to agency on 8/29/22 with diagnoses including Bilateral Primary Osteoarthritis of Knee and Primary Osteoarthritis Right Shoulder. A HV was conducted on 9/13/22 at 1:40 PM to observe care provided by EI # 7, OT. EI # 5, RN, was also present during the HV. During the visit, the current medicine list provided by the agency on 9/13/22 was compared to the medications observed in the home. The following medications were observed in the patient's home, but were not on the medicine list. a. Hydrochlorothiazide 25 mg tablet, one tablet daily. The medicine bottle was dated 8/31/22 was observed with HV # 5's medications and the patient stated, "I've been taking it since 2015." b. Over the Counter (OTC) Prevagen one capsule daily. The patient reported she/he has been taking the medication for almost one year. c. OTC Turmeric 1000 mg one tablet twice a day. The patient reported she/he has been taking the medication for 2 months. d. OTC Vital Vitamins - Collagen Complex 1500 mg/50 mg, one tablet twice daily. The patient reported she/he has been taking the medication for about 2 weeks. The following medication was on the medicine list, but was not observed in the patient's home: a. Alive Hair, Skin and Nails, 1250 Micrograms (mcg) - 50 mg - 67.5 mg - 15 mg chew, one tablet daily. Patient reported she/he had stopped taking the medication about 2 weeks ago. An interview was conducted on 9/15/22 at 10:33 AM with EI # 5, who confirmed staff failed to update the medication list. 1. HV # 2 was admitted to the agency on 5/14/22 with diagnoses including Cellulitis of Left Lower Limb, and Pressure Ulcer of Right Heel, Stage Two, and recertified for care 7/13/22 to 9/10/22. A HV was conducted on 9/13/22 at 11:45 AM to observe care provided by Employee Identifier (EI) # 2, RN. EI # 4, RN was also present during the visit. During the visit, the current Medicine List, printed on 9/13/22, was compared to the medicines found in the home. The following discrepancies were observed: a. Amlodipine 10 mg (milligrams), one tablet daily was on the medicine list. The patient stated the Amlodipine was discontinued on 8/13/22. b. Ferosul 325 mg, one tablet daily was on the medicine list. The bottle in the home read one tablet three times daily. The date filled was 8/24/22. HV # 2 stated he/she took the Ferosul three times daily. c. Lisinopril 5 mg, one tablet daily was in the home and not on the medicine list. Date filled on the bottle was 8/13/22. HV # 2 confirmed he/she started the Lisinopril once a day on 8/13/22. An interview was conducted on 9/15/22 at 10:40 AM with EI # 8, Home Health Director, who confirmed staff failed to update the medicine list. 2. HV # 3 was admitted to the agency on 7/5/22 and recertified for care for 9/3/22 to 11/1/22. Diagnoses included Displaced Oblique Fracture Shaft of Right Femur, and Muscle Weakness (Generalized). A HV was conducted on 9/13/22 at 1:00 PM to observe physical therapy services provided by EI # 3, PT. EI # 4 was also present during the HV. During the visit, the current Medicine List, printed on 9/13/22, was compared to the medicines found in the home. The following discrepancies were observed: a. Acetaminophen Extra Strength 500 mg, two tablets daily was on the medicine list. The patient stated she/he has taken one tablet daily "... for a long time." b. Ed A-Hist 4 mg - 10 mg, one tablet three times daily was on the medicine list. Patient stated she/he takes the medicine as needed for allergies, and has not used the medicine three times daily. An interview was conducted on 9/15/22 at 10:20 AM with EI # 9, OASIS (Outcome and Assessment Information Set), RN, who confirmed staff failed to update the medicine list.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, review of policy and procedure, and interviews, it was determined the agency failed to ensure staff maintained infection control per agency procedure. This affected Home Visit (HV) # 4, one of seven HV's conducted, and had the potential to negatively affect all patient admitted to this agency. Findings include: Agency Policy: Catheter: Foley Catheter Care Agency Policy Number: None Listed Revised Date: 3/2021 Policy: Care of an indwelling urinary catheter will be provided during the bathing process by the Home Health Aide (HHA) as ordered... II. Purpose: A. To reduce risk of infections from an indwelling urinary catheter. B. To promote and maintain good hygiene of patient. ...IV. Equipment: A. Clean washcloth... V. Procedure: E. With a clean, wet washcloth and soap, clean the ...indwelling catheter... VIII. Special Points: C. If using bath soap, rinse well with clean, warm tap water to prevent skin irritation. Agency Procedure Guide: Bathing The Client Chapter 35 pages 374-376 Complete Bed Bath 25. Empty the basin, rinse, and refill it with clean water... 26. Assist the client to turn on his or her side so the back is toward you. 27. ...Wash, rinse, and dry the client's ...back and buttocks... 29. Empty the basin, rinse, and refill it with clean water... 30. ...wash his or her perineal area, provide a soapy washcloth, then a clean, wet cloth for the rinse... 1. HV # 4 was admitted to the agency on 9/15/2020 and recertified for care from 9/5/22 to11/3/22 with diagnoses including Encounter for Fitting and Adjustment of Urinary Device and Retention of Urine, Unspecified. A HV was conducted on 9/13/22 at 11:40 AM to observe Employee Identifier (EI) # 6, Home Health Aid (HHA) provide care. EI # 5, RN was also present during the HV. After washing and rinsing legs and feet of HV # 4, the surveyor observed EI # 6 use the same washcloth to rinse the perineal area including the foley catheter and urinary meatus of HV # 4, then without changing washclothes washed and rinsed HV # 4's back. An interview was conducted on 9/15/22 at 10:07 AM with EI # 5 who confirmed the aide did not follow the policy to promote good hygiene while providing a bath for a patient with a foley catheter.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on a review of medical records (MR), observations, agency policy and procedure, and staff interviews, it was determined the agency failed to ensure medical record documentation was accurate and complete, and orders were entered timely into the Electronic Medical Record (EMR). This affected three of 12 current records reviewed, and did affect MR # 2, Home Visit (HV) # 7, and MR # 5, and had the potential to affect all patients served by the agency. Findings include: Agency Policy: EMR Documentation Requirements Policy number: None listed Date Reviewed: March 2021 I. Policy: All staff must utilize the automated system to document clinical care, orders...All documents must be completed and submitted timely... II. Purpose: To ensure timely documentation of information on medical records for all the patients receiving services...To ensure accuracy of documentation... III. Procedure: A. ...Staff must utilize "print preview" feature to ensure documentation is complete and accurate... B. All physician orders are entered into the computer when received and exported back to the server prior to 11:30 PM. 2. HV # 7 was admitted to the agency on 8/24/22 with diagnoses including Chronic Venous Hypertension With Ulcer of Left Lower Extremity, and Non-Pressure Chronic Ulcer Other Part Left Lower Leg With Fat Layer Exposed. Review of the HHC and POC for certification period 8/24/22 to 10/22/22 revealed a SN visit frequency of two times a week for three weeks, one time a week for three weeks, and two PRN (as needed) visits. Further review of the HHC and POC dated 8/24/22 revealed an order for wound care to wound # 3, cellulitis of left calf as follows: "Cleanse with Vashe or Normal Saline (NS), apply Xeroform, cover with dry gauze. Wrap with rolled gauze and secure with tape. Wound care to be performed daily and PRN." Review of the 8/29/22 wound care order revealed a change in wound care as follows: "Cleanse with Vashe or NS, apply silicone layer to base of wound daily, cover with four by four (4 x 4) gauze and kerlix (rolled gauze) loosely." Review of the 9/7/22 SN VNR Wound Assessment revealed the SN documented the entire 8/24/22 wound care order that utilized Xeroform, and also documented, "Patient tolerated procedure well, using adaptic (silicone) to wound bed," in the Wound Assessment. The SN did not document the wound care he/she provided accurately. Review of the facsimile cover sheet from the Wound Healing Center dated 9/12/22 with wound care orders dated 9/12/22 13:54 (1: 54 PM) revealed new wound care orders as follows: "Cleanse with Vashe or NS, apply silicone layer to base of wound and cover with hydrofera blue ready transfer daily. Cover with 4 x 4 gauze and kerlix loosely applied. Apply very loose ace dressing." A HV was conducted 9/13/22 at 1:42 PM to observe wound care provided by EI # 10, Licensed Practical Nurse (LPN). EI # 8, Home Health Director, was also present. After EI # 9 removed the old outer dressing to wound # 3, a hydrofera blue was observed covering the wound. EI # 9 cleansed the wound with Vashe, applied silicone to the wound base, and began to cover with 4 x 4 gauze. HV # 7 requested EI # 9 place hydrofera blue before placing the 4 x 4 gauze. EI # 9 reviewed the current wound care orders in the EMR, and stated there was no order for hydrofera blue. The agency failed to enter the new orders for wound care on the day they were received per policy. An interview conducted on 9/15/22 at 10:52 AM with EI # 8 confirmed the SN did not document accurately on the 9/7/22 visit, and that the order received 9/12/22 for wound care should have been in the EMR on 9/13/22 and was not. 3. MR # 5 was admitted to the agency on 8/24/22 with diagnoses including Malignant Neoplasm of Anal Canal, and Malignant Neoplasm of Head of Pancreas. Review of the HHC and POC dated 8/24/22 to 10/22/22 revealed orders for the SN to cleanse the Groshong (Intravenous Catheter) site with Chloroprep and apply bandaid weekly. "SN to flush Groshong weekly using sterile technique with 10 cc's NS and apply alcohol cap after flush and change weekly." Review of the SN VNR dated 8/31/22 revealed, "Site care performed to Groshong, and SN flushed with 10 cc NS. Patient tolerated well." There was no documentation the SN cleansed the site with Chloroprep, applied a bandaid, or changed the injection cap after flushing. The SN failed to document completely and accurately the site care he/she provided. An interview conducted on 9/15/22 at 10:32 AM with EI # 8 confirmed the SN documentation of site care was not accurate and complete. 1. MR # 2 was admitted to the agency on 2/15/22 with diagnoses including Encounter For Fitting and Adjustment of Urinary Device and Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease. Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 6/15/22 to 8/13/22 revealed, Skilled Nurse (SN) to perform foley catheter change using sterile technique, insert # 16 F (French) / 5 cc (cubic centimeters) foley catheter and instill 10 ml (milliliters) of sterile water into bulb. Further review of the HHC and POC dated 6/15/22 to 8/13/22 revealed, Medications: Glipizide 5 mg (milligram) 1 tablet daily with evening meal and Rybelsus 7 mg 1 tablet daily. Review of the SN Visit Note Report (VNR) dated 8/10/22 revealed, "Catheter changed using sterile technique: 16F 5cc catheter inserted upon removal of old catheter and secured to thigh using statlock". There was no documentation of the type and amount of fluid used to inflate the bulb of the catheter per agency policy. Further review of the SNVNR dated 8/10/22 revealed, "Patients daughter checks blood sugars regularly and administers insulin as scheduled and is able to provide demonstration of this procedure". There was no documentation of Insulin in the POC medications listed. Review of the SNVNR dated 9/9/22 revealed, "SN placed a 16F 5cc catheter using sterile technique". There was no documentation of the type and amount of fluid used to inflate the bulb of the catheter per agency policy. An interview was conducted on 9/15/22 at 10:55 AM with Employee Identifier (EI) # 9, Outcome and Assessment Information Set (OASIS) Review Registered Nurse (RN), who confirmed the staff failed to document the type and amount of fluid used to inflate the bulb of the catheter. EI # 9 further stated that MR # 2 was not on Insulin and that the SN documented inaccurately in the MR.