Every finding on record at Er Home Health, Inc

The following reflects the findings of the California Department of Public Health during a Recertification Survey and for Change of Location (CHOL). Representing the California Department of Public Health: Surveyor # 44911, Health Facilities Evaluator Nurse Surveyor # 09697, Health Facilities Evaluator Nurse Unduplicated Admissions - 54 Active Patients - 38 Sample Size - 7 Patients Home Visits – 3 On 12/7/2022, at 11:11 AM, an onsite visit was conducted at the home health agency’s new address (2001 W. Beverly Blvd. Unit B, Montebello, CA 90640). The Administrator (ADM) designee/Director of Patient Care Services (DPCS) was informed of the purpose of the visit. A tour was conducted at the office with the ADM designee/DPCS. The current organizational chart and lease agreement were requested and reviewed. The agency was found in compliance with applicable State regulations and requirements for home health agency. Licensure approved and granted on 12/7/2022. Old Address: 433 N. 4th St. Suite 202 Montebello, CA 90640-4309 New Address: 2001 W. Beverly Blvd. Unit B Montebello, CA 90640

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) failed to review and update the discontinued medication and indicate the accurate dosage of the pain medication in the patient's medication profile for one of seven (Patient 1) sampled patients. This deficient practice has the potential risk to cause medication errors and adverse drug reactions. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/8/2021, with a primary diagnoses of displaced fracture of left lateral condyle of the femur (break in the lower outer part, near the knee, of the long bone of the upper leg), hemiplegia (paralysis of one side of the body), and hemiparesis (another term for hemiplegia) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the left non-dominant side, and history of falling. A review of Patient 1’s Plan of Care (POC) for certification period from 11/3/2022 to 1/1/2023, indicated Skilled Nurse (SN) to visit once a week for eight weeks to perform skilled assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications, knowledge and compliance to prescribed medications. The POC indicated the Medication Dose/Frequency/Route as follows: Aspirin 81 milligrams (mg.), one tablet taken by mouth once daily Tylenol 325 mg., two tablets four times daily as needed for pain. A review of Patient 1’s Patient Medication Profile for certification period from 11/3/2022 to 1/1/2023 indicated the following medication orders: Aspirin 81 mg., one tablet taken by mouth once daily Tylenol 325 mg., two tablets taken four times daily as needed for pain On 12/6/2022, at 9:42 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 1’s residence. Patient 1 was lying in hospital bed with padded side rails up and in place. Patient 1’s patient/family caregiver (PCG) was also in the home. During a concurrent interview and review on 12/6/2022, at 9:53 AM, of Patient 1’s medications with LVN 1, it was noted Patient 1 had one bottle of acetaminophen (generic for Tylenol) 500 mg. tablets. LVN 1 verified the Medication Profile in Patient 1’s admission packet which indicated an order for Tylenol 325mg., and not acetaminophen 500 mg.. LVN 1 stated she did not realize the different medication dosages. A review of Patient 1’s physician orders, dated 11/3/2022, indicated to discontinue Aspirin 81mg., one tablet taken by mouth once daily. The Medication Profile indicated Aspirin 81mg., was discontinued on 11/12/2022. During an interview on 12/6/2022, at 10:21 AM, with LVN 1, stated it was important to review the medications with the doctor’s order and update the POC and Medication profile to ensure the patient takes all medications as ordered and avoid any adverse effects. During an interview on 12/7/2022, at 12:47 PM, with the Director of Patient Care Services (DPCS), the DPCS stated the medication reviews should be completed by the SN during every patient visit and the POC and medication profile should be updated to ensure the patient is taking the correct medications according to the doctor’s orders. DPCS stated reviewing the medications helps to assess for any adverse effects and reactions as well as evaluates the correct therapy for the patient. A review of the HHA’s policy and procedure (P&P) titled “Care Planning Process”, revised 4/2021 indicated all clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including clinical drug monitoring, as appropriate.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide services in accordance with the plan of care (POC) for three of seven patients (Patient 1, 2, and 6). The deficient practice has the potential in the delay to inform the physician of the patient's significant changes of condition for further treatment and intervention that could impact the patients' clinical status and well and well-being. Findings: a. A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/8/2021, with diagnoses of displaced fracture of left lateral condyle of the femur (break in the lower outer part, near the knee, of the long bone of the upper leg), hemiplegia (paralysis of one side of the body), and hemiparesis (another term for hemiplegia) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the left non-dominant side, and history of falling. A review of Patient 1’s Recertification Assessment, dated 11/2/2022 indicated a primary diagnosis of pressure ulcer (localized injury to the skin and underlying tissue as a result of pressure) of left ankle, Stage 4 (pressure injury that is very deep, reaching into muscle and bone and causing extensive damage). It indicated under SN Professional Services-wound care to include the SN to measure the wound weekly. A review of Patient 1’s Plan of Care (POC) for certification period from 11/3/2022 to 1/1/2023, indicated Skilled Nurse (SN) to visit once a week for eight weeks to perform skilled assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications. It indicated for SN to perform/instruct/validate to patient/caregiver (PCG) regarding infection control measure of wound care, signs and symptoms of infection, prevention of further skin breakdown. It indicated a goal/rehabilitation potential of a decrease in size of the patient’s left ankle wound to 90% this certification period. It indicated under other notes SN will render wound care and teach PCG if SN is not scheduled to visit patient. A review of Patient 1’s Wound Care Flow Sheet dated 11/2/2022 indicated patient’s wound to left ankle measured dimensions of 0.7 centimeters (cm) in length, 0.7 cm in width, and 0.2 cm in depth. A review of Patient 1’s Wound Care Flow Sheet dated 11/9/2022 indicated patient’s wound to left ankle measured dimensions of 0.6 centimeters (cm) in length, 0.7 cm in width, and 0.2 cm in depth. On 12/6/2022 at 9:42 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 1’s home residence. Patient 1 was lying in hospital bed with padded side rails up and in place. Patient 1’s patient/family caregiver (PCG) was also in the home. During an observation on 12/6/2022, at 9:53 AM, it was observed LVN 1 was providing wound care to Patient 1. It was further observed LVN 1 did not perform wound assessment that included the measurements after cleansing the wound and before applying dressing. During an interview on 12/6/2022, at 10:21 AM, with LVN 1, stated she was supposed to measure Patient 1’s wound to left ankle but she did not bring a ruler to measure the wound. LVN 1 stated the importance of measuring the patient’s wound to assess the progress or decline of the pressure injury wound and to assess if the current wound treatment was working or not. During an interview on 12/7/2022, at 12:47 PM, with Director of Patient Care Services (DPCS), stated the importance of the SN to measure Patient 1’s wound every home visit to evaluate if the treatment plan for the wound needs to be changed or continued. DPCS stated if the goal on the patient’s POC was to reduce the size of the wound, the way to achieve this goal was to measure the wound every week as the comprehensive assessment indicates. b. During a closed record review of Patient 2’s profile indicated a Start of Care (SOC) date of 5/16/2022, with diagnoses of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long period of time), heart failure (when the heart muscle does not pump blood as well as it should), pneumonia (bacterial or viral infection that inflames air sacs in one or both lungs, which may fill with fluid), acute (sudden onset) and chronic (condition that lasts for three months or longer and may get worse over time) respiratory failure (failure of the lungs to meet the oxygen demand of the body that results in difficulty breathing) with hypoxia (lack of oxygen in the tissues to sustain bodily function). A review of Patient 2’s Plan of Care (POC) for certification period from 5/16/2022 to 7/14/2022, indicated SN to visit twice a week for one week, then once a week for eight weeks to perform skilled nursing assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications. It indicated SN to perform observation and assessment of vital signs and pulmonary status. It indicated for SN to notify the doctor if Patient 2’s O2 saturation (O2 sat-oxygen level in the blood) is at or below 92%, call doctor immediately if O2 sat drops to 4% below baseline for more than five minutes with vital sign changes (increase respiratory rate, heart rate, blood pressure, call doctor immediately). A review of Patient 2’s SN Visit Notes dated 5/20/2022, 5/27/2022, and 6/3/2022, indicated Patient 2 was receiving oxygen therapy at 2 liters per minute (LPM), had shortness of breath, and diminished lung sounds. There was no documented evidence O2 sat was recorded. During a concurrent interview and record review on 12/7/2022, at 12:47 PM, with DPCS of Patient 2’s SN visit notes and POC, DPCS stated when SN checks a patient’s vital signs, this includes checking the blood pressure, temperature, heart rate, respirations, and O2 sat if there is a respiratory issue. DPCS stated if a patient is receiving oxygen therapy, the O2 sat should be checked and documented. DPCS verified that Patient 2 was receiving oxygen therapy according to the plan of care. DPCS verified the SN Visit Notes dated 5/20/2022, 5/27/2022, and 6/3/2022, did not document the O2 sat levels. DPCS stated the importance of assessing and documenting the O2 sat in order to monitor the patient’s respiratory status and make sure the therapy if working or needs to be changed. A review of the HHA’s policy and procedure (P&P) titled “Care Planning Process”, revised 4/2021 indicated the purpose was to provide clinical direction to clinicians providing direct patient care. The P&P indicated under Procedure: 3. Based on the assessment and conclusions, the plan of care will include, but not be limited to: D. Reasonable, measurable, and individualized goals and outcomes identified by the organization and the patient anticipated to occur as a result of implementing and coordinating the plan of care, E. Specific services and treatments to be provided, and F. Actions to be taken to meet the patient goals. A review of the HHA’s P&P titled, “Parameters”, revised 6/1/2013 indicated the HHA will have parameters (set of limits) that all personnel will use as to when it is necessary to phone the doctor and when it is not. c. A review of Patient 6’s clinical record disclosed a start of care date on 3/23/22, with diagnoses of chronic venous hypertension, non-pressure ulcer both lower extremities, and chronic kidney disease. During the certification period of 11/18/22 through 1/16/23, the POC indicated for skilled nurse (SN) visit twice a week for 8 weeks. The SN was to perform skilled nursing assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms complications and exacerbation, knowledge and compliance to prescribed medications regimen, functional mobility, ability self-care and home safety. SN to assess and document the patient’s pain characteristics that included sharp pain, crushing, burning, severity of pain in the scale of 1-10, location, onset, duration, and precipitating or severe factors ; implement pain relief measures to include non-pharmacologic measures which may include coping techniques like relaxation, repositioning, diversion and use of imagery if pain is experienced; evaluate effectiveness. A review of Patient 6's SN notes dated 11/12/22, 11/13/22,11/21/22,11/26/22, and 11/28/22, indicated no evidence the pain to the right lower extremity was assessed and documented interventions to relieve pain. On 12/7/22, at 12:30 p.m., RN 1 explained the licensed nurse should have completed the pain assessment and management on each specific pain site.

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 observation, interview, and record review, the home health agency (HHA) failed to follow the doctor’s order for two of seven patients (Patients 1 and 2). This deficient practice has the potential to cause adverse reactions and ineffective drug therapy. Findings: a. A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/8/2021, with diagnoses of displaced fracture of left lateral condyle of the femur (break in the lower outer part, near the knee, of the long bone of the upper leg), hemiplegia, (paralysis of one side of the body), and hemiparesis (another term for hemiplegia) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the left non-dominant side, and history of falling. A review of Patient 1’s Plan of Care (POC) for certification period from 11/3/2022 to 1/1/2023, indicated SN to visit once a week for eight weeks to perform skilled assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications, knowledge and compliance to prescribed medications. The POC indicated the Medication Dose/Frequency/Route for Tylenol 325 mgs, two tablets four times daily as needed for pain. A review of Patient 1’s Patient Medication Profile for certification period from 11/3/2022 to 1/1/2023, indicated the following medication orders: Tylenol 325 mg., two tablets four times daily as needed for pain. On 12/6/2022, at 9:42 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 1’s residence. Patient 1 was lying in hospital bed with padded side rails up and in place. Patient 1’s patient/family caregiver (PCG) was also in the home. During a concurrent interview and review on 12/6/2022, at 9:53 AM, of Patient 1’s medications with LVN 1, it was noted Patient 1 had a bottle of acetaminophen (generic for Tylenol) 500mg tablets. LVN 1 verified the Medication Profile in the admission packet and indicated an order for Tylenol 325mg. LVN 1 stated she did not realize the different medication dosages. During an interview on 12/6/2022, at 10:21 AM, with LVN 1, stated it was important to review the medications and follow the doctor’s order and update the POC and Medication profile to ensure the patient takes all medications as ordered and avoid any adverse effects. During an interview on 12/7/2022 at 12:47 PM with the Director of Patient Care Services (DPCS), stated the POC and medication profile should be updated to ensure the patient was taking the correct medications according to the doctor’s orders. b. During a closed record review of Patient 2’s profile indicated a Start of Care (SOC) date of 5/16/2022, with diagnoses of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long period of time), heart failure (when the heart muscle does not pump blood as well as it should), pneumonia (bacterial or viral infection that inflames air sacs in one or both lungs, which may fill with fluid), acute (sudden onset) and chronic (condition that lasts for three months or longer and may get worse over time) respiratory failure (failure of the lungs to meet the oxygen demand of the body that results in difficulty breathing) with hypoxia (lack of oxygen in the tissues to sustain bodily function). A review of Patient 2’s Plan of Care (POC) for certification period from 5/16/2022 to 7/14/2022, indicated SN to visit twice a week for one week, then once a week for eight weeks to perform skilled nursing assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications. It indicated SN to perform observation and assessment of vital signs and pulmonary status. It indicated for SN to notify the doctor if O2 sat was at or below 92%, call doctor immediately if O2 sat drops to 4% below baseline for more than five minutes with vital sign changes (increase respiratory rate, heart rate, blood pressure, call doctor immediately). The POC indicated an order for oxygen at 3 LPM via nasal cannula for shortness of breath. A review of Patient 2’s SN Visit Notes dated 5/20/2022, 5/27/2022, and 6/3/2022, indicated Patient 2 was receiving oxygen therapy of 2 liters per minute (LPM), had shortness of breath and had diminished lung sounds. There was no documented O2 sat recorded. During a concurrent interview and record review on 12/7/2022, at 12:47 PM, with DPCS of Patient 2’s SN visit notes and POC, DPCS verified Patient 2’s POC indicated an order for oxygen to be administered at 3 LPM via nasal cannula for shortness of breath. DPCS verified the SN Visit Notes dated 5/20/2022, 5/27/2022, and 6/3/202, indicated the SN documented Patient 2 received oxygen at 2 LPM. DPCS stated the doctor’s orders should be followed so the patient receives the proper therapy. A review of the HHA’s policy and procedure (P&P) titled “Physician Orders”, revised 9/1/2013 indicated treatments and medications shall be administered to patients only as ordered by the patient’s Physician. A review of the HHA’s P&P titled “Oxygen Therapy”, undated, indicated the type of therapy given and any specified modalities will be in accordance with specific doctor’s orders.

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 record review, and staff interview, the agency's nursing staff failed to provide services that included pain assessment and intervention for one of 7 sampled patient (6). This deficient practice has the potential to result in patient's unresolved pain and discomfort that could affect their quality of life and well-being. Findings: A review of Patient 6’s clinical record disclosed a start of care date on 3/23/22, with diagnoses of chronic venous hypertension, non-pressure ulcer both lower extremities, and chronic kidney disease. During the certification period of 11/18/22, to 1/16/23, the POC indicated for Skilled nurse (SN) visit twice a week for 8 weeks. The SN was to perform skilled nursing assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms complications and exacerbation, knowledge and compliance to prescribed medications regimen, functional mobility, ability self-care and home safety. Skilled nurse to assess and document the patient’s pain characteristics that included sharp pain, crushing, burning, severity of pain scale of 1-10), location, onset, duration, and precipitating or severe factors; implement pain relief measures to include non-pharmacologic measures which may include coping techniques like relaxation, repositioning, diversion and use of imagery if pain is experienced; evaluate effectiveness. The skilled nursing notes dated 11/12/22; 11/13/22;11/21/22;11/26/22, and 11/28/22, indicated Patient 6’s assessment on her right lower extremity was 5/10 and left lower extremity was 3/10, (pain scale as 0 as no pain and 10 as severe pain). There was no documented evidence that an intervention was provided and no evaluation of the pain. On 12/7/22, at 12:30 p.m., RN 1 explained the licensed nurse should have completed the pain assessment and management on each specific pain site.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide education regarding medication to patient/caregiver for one of seven (Patient 1) sampled patients. This deficient practice had the potential to result in medication errors, adverse reactions, and ineffective drug therapy. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/8/2021 with diagnoses of displaced fracture of left lateral condyle of the femur (break in the lower outer part, near the knee, of the long bone of the upper leg), hemiplegia (paralysis of one side of the body), and hemiparesis (another term for hemiplegia) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the left non-dominant side, and history of falling. A review of Patient 1’s Plan of Care (POC) for certification period from 11/3/2022 to 1/1/2023 indicated Skilled Nurse (SN) to visit once a week for eight weeks to perform skilled assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications, knowledge and compliance to prescribed medications. The POC indicated the SN to instruct patient/caregiver (PCG) about the medications, dosage, purpose, action/frequency, side effects. The POC indicated the Medication Dose/Frequency/Route as follows: Tylenol 325 mgs, two tablets four times daily as needed for pain. A review of Patient 1’s Patient Medication Profile for certification period from 11/3/2022 to 1/1/2023 indicated a medication order of Tylenol 325 mg, two tablets taken four times daily as needed for pain On 12/6/2022, at 9:42 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 1’s residence. Patient 1 was lying in hospital bed with padded side rails up and in place. Patient 1’s patient/family caregiver (PCG) was also in the home. During a concurrent interview and review on 12/6/2022, at 9:53 AM, of Patient 1’s medications with LVN 1, it was noted a bottle of acetaminophen (generic for Tylenol) 500 mg tablets. LVN 1 verified the Medication Profile in Patient 1’s admission packet indicated an order for Tylenol 325mg. LVN 1 stated she did not realize the different medication dosages. During an interview on 12/6/2022 at 10:13 AM, with Patient 1’s PCG, the PCG stated she was not aware of the incorrect dosages of Tylenol 500 mg from what the doctor ordered which was Tylenol 325mg. During an interview on 12/6/2022 at 10:21 AM, with LVN 1, stated Patient 1 and PCG needs re-education regarding the correct dosage of Tylenol as ordered by the doctor. LVN 1 stated the importance of educating the patient and PCG regarding their medications ordered to avoid any adverse effects and ensure the patient is taking the correct medications. During an interview on 12/7/2022 at 12:47 PM, with the Director of Patient Care Services (DPCS), stated the SN should review and educate the patient/PCG regarding their medications as ordered by the doctor every SN home visit to ensure the patient was taking the correct medications as well as identify any adverse reactions. A review of the HHA’s policy and procedure (P&P) titled “Patient Education Process”, revised 4/2021, indicated the policy patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate, education will be in the responsibility of each clinician and will focus on increasing patient and family/caregiver potential to follow the plan of care. The P&P indicated the procedure to implement will include the patient and family/caregiver will receive verbal and, as appropriate, written instructions that are in plain language that does not use medical abbreviations regarding medication management and administration. A review of the HHA’s P&P titled “Care Planning Process”, revised 4/2021, indicated all clinicians will consider the conclusions of initial and ongoing assessments in their care planning process, including, but not limited to patient and caregiver education and training that the organization will provide specific to the patient’s care needs.

Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the licensed nurse failed to communicate with the physician of the correct medication dosage taken by the patient for one of seven (Patient 1) sampled patients. This deficient practice had the potential to lead to the patient not receiving the proper dosage of pain medication and lead to adverse reactions. Findings: A review of Patient 1’s profile indicated a Start of Care (SOC) date of 11/8/2021, with diagnoses of displaced fracture of left lateral condyle of the femur (break in the lower outer part, near the knee, of the long bone of the upper leg), hemiplegia (paralysis of one side of the body), and hemiparesis (another term for hemiplegia) following cerebral infarction (occurs as a result of disrupted blood flow to the brain) affecting the left non-dominant side, and history of falling. A review of Patient 1’s Plan of Care (POC) for certification period from 11/3/2022 to 1/1/2023 indicated Skilled Nurse (SN) to visit once a week for eight weeks to perform skilled assessment and observation of all body systems, obtain vital signs and identify trends, signs and symptoms of complications, knowledge and compliance to prescribed medications. The POC indicated the Medication Dose/Frequency/Route as follows: Tylenol 325 mgs, two tablets four times daily as needed for pain. The POC indicated the SN to notify the doctor if patient’s pain is not relieved after two doses of pain medication. The POC indicated if patient does not have prescribed medication, a request will be made within four hours to doctor. A review of Patient 1’s Patient Medication Profile for certification period from 11/3/2022 to 1/1/2023 indicated a medication order of Tylenol 325 mg., two tablets taken four times daily as needed for pain On 12/6/2022, at 9:42 AM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 1’s residence. Patient 1 was lying in hospital bed with padded side rails up and in place. Patient 1’s patient/family caregiver (PCG) was also in the home. During a concurrent interview and review on 12/6/2022 at 9:53 AM, of Patient 1’s medications with LVN 1, it was noted Patient 1 had one bottle of acetaminophen (generic for Tylenol) 500 mg tablets. LVN 1 verified the Medication Profile in Patient 1’s admission packet indicated an order for Tylenol 325mg. LVN 1 stated she did not realize the different medication concentration. During an interview on 12/7/2022, at 12:47 PM, with DPCS, stated the SN should communicate the difference in concentration of Tylenol pain medication for Patient 1 to the doctor to ensure the doctor was aware of the medication the patient was taking and gave the doctor the opportunity to either agree to the different concentration or the to communicate a need for change of the medication. A review of the HHA’s policy and procedure (P&P) titled “Ongoing Assessments”, revised 4/2021, indicated the purpose of the policy is to provide guidelines for assessments of patient’s during ongoing care. The P&P indicated the physician will be notified to verify any changes in medications, including over-the-counter medications which might interact or be duplicative with other patient medications, and care, treatments, or services that require physician approval.