Every finding on record at Hiawatha Homecare

On 2/27/23 - 3/1/23 a complaint survey was conducted. This resulted in a standard survey at Hiawatha Home Care. The agency was found to have not met the requirements at 42 CFR. Part 484 for Home Health Agencies. The cumulative effects of these findings resulted in the Home Health Agency’s inability to ensure provision of quality of care. H72888564C/Intake 96196 was substantiated deficiencies were issued at G430, G434, G476, and G526 were issued complaint investigation The Condition of Participation: Patient Rights at 42 CFR 484.50 at G430 and G476 was found not met.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency (HHA) failed to meet the Condition of Participation: Patient Rights 484.50 was not met. The agency failed to ensure 1 of 1 patient (P1) was not physically, mentally, and verbally abused when registered nurse (RN)-A was witnessed on video recording forcefully pushing P1's head into the pillow, tossing P1’s across his body, slamming ventilator tubing against P1’s abdominal. RN-A was also heard on the footage yelling profane language at P1. In addition, the agency failed to thoroughly investigate an incident of abuse. Refer to G430: The agency failed to ensure mental, physical, and verbal abuse for 1 of 3 patients (P1), reviewed for abuse. P1 was a ventilator-dependent patient, received tube feeding, oxygen, suctioning, catheter care, turning and repositioning. RN-A had been working 12 hour shifts full-time with P1 since 1/29/23. RN-A because frustrated with the extent of P1’s cares and not having personal care attendant (PCA) services for three consecutive days, RN-A was seen on video footage yelling profane language at P1 and physically hitting, pushing his head against the pillow while pulling his hair and roughly moving his arm. Refer to G476: The agency failed to thoroughly investigate an incident of abuse for 1 of 1 patient (P1) who was a ventilator-dependent patient, received tube feeding, oxygen, suctioning, catheter care, turning and repositioning. The agency failed interview other nursing staff who worked with P1, the family member who initially reported abuse or any other agency coordinating patient care.

Be free from abuse CFR(s): 484.50(c)(2) Be free from verbal, mental, sexual, and physical abuse, including injuries of unknown source, neglect and misappropriation of property; This ELEMENT is not met as evidenced by: Based on interview and document review the agency failed to ensure the patient was free from abuse for 1 of 3 patient's reviewed (P1), when a Registered Nurse (RN)-A was recorded on video abusing the client, including forcefully pushing P1's head into the pillow, tossing P1’s across his body, slamming ventilator tubing against P1’s abdominal. RN-A was also heard on the footage yelling profane language at P1. P1's POC dated 1/28/23, indicated P1 had chronic respiratory insufficiency and was dependent on a ventilator. P1 had dysphagia (unable to speak), osteoporosis, and chronic pain. The POC further indicated skilled nursing (SN) services 20-24 hours a day. In addition, the POC indicated skilled nursing services administered medications via gastrostomy tube (g-tube), tracheostomy cares, catheter cares, turning and repositioning cares, and continuous ventilator cares. A review of P1's staffing schedule revealed RN-A provided the complex RN care for P1 a few shifts a week starting 1/17/21-1/18/23. RN-A began working full-time 12-hour shifts with P1 on 1/29/23. A review of the video footage from 2/16/23, video clip #1 showed RN-A tossing P1’s arm across his body as RN-A was changing his incontinence pad. RN-A stated “That is all you do shit all day long. Shut up, I am not kidding, shush.” Video clip #2 showed RN-A forcefully pushes VA’s head back pushing it to the pillow while grasping his hair and pulling. The audio heard was “What?” “What’s wrong?” “Now I’m going to have to change you for the third time today, so what are you complaining about now?” Video clip #3 showed P1 laying on his right side continuing to have his incontinent pad changed. RN-A threw her arms in the air and yelled “God, I [expletive] hate you.” Video clip #4 showed P1 laying on his back with his incontinent brief intact. RN-A was looking for something, as she was looking around, she slammed the ventilator tube on his chest. She then walks to the other side of P1’s bed and throws pillows around on his bed. She takes a seat with him on his bed, RN-A started crying and stated to P1 “You know what you would probably be happier if I was dead too.” P1 is heard moaning throughout the video clip. Upon interview on 2/27/23, at 10:55 a.m. FM-B stated FM-A and FM-B were on vacation and the family member FM-C, who stayed at home contacted FM-A and FM-B on 2/16/23, at around 4:15 p.m. stating she overhead RN-A yelling at P1. FM-A and FM-B immediately watched video camera footage from the shift of 2/16/23. On the video RN-A was seen pushing P1s head again his pillow with his hair being pulled, the slamming of his ventilator tube on his abdomen and tossing his arm onto the bed. RN-A was heard making statements of “I [expletive] hate you.” “All you do is poop all day.” “What could you possible want?” RN-A was then visualized sitting on P1’s bed crying and stating, “I bet you wish I was dead too.” FM-B stated he considered this treatment physical, verbal, and mental abuse as P1 can understand what was being said to him. FM-A and FM-B watched the video live on 2/16/23, until RN-As shift was over at 7:00 p.m. At around 5:30 p.m. FM-B called FM-C at the home and asked her to go and check on P1 because it appeared on the video RN-A was getting “flustered again.” FM-C checked on P1 and assisted RN-A with changing P1’s incontinent brief. Upon interview on 2/27/23, at 2:50 p.m. the director or nursing (DON) stated she had watched the video and RN-A was acting crazy and having a nervous breakdown. The DON stated the agency RN-A was written-up for tardiness on 12/22/22 and during her orientation to P1 she was slow to pick-up the ventilator training and cares, which required additional training. After viewing the video and speaking with RN-A, the agency found RN-As behavior to be mentally physically and verbally abusive. Upon interview on 2/28/23 at 7:52 a.m. RN-A stated she had a meltdown by saying “I yelled at P1.” “I swore at P1.” “I hit P1.” RN-A stated FM-A and FM-B were on a vacation and P1’s schedule was arranged so that RN-A would have assistance of a personal care attendant (PCA)-A. PCA-A from another agency was out ill, missing three days of work during the week of the family’s vacation. RN-A stated P1s cares are hard to do specially to clean him up with one person due to vent and gastrostomy tube (g-tube). The g-tube leaked for the third time on the shift on 2/16/23, RN-A stated she “lost it”. It was a really hard day, because P1 had three stools that day and she had to change him alone. RN-A stated she was a small person, P1 was a large patient, and moving him alone is difficult. RN-A denied reporting her care concerns to the agency at any time. RN-A did not answer when asked why she refused the help from FM-C when she asked if she could assist. RN-A did not report her yelling or abusive cares with P1 to the agency or the oncoming nurse on 2/16/23. Upon interview on 2/28/23, at 4:07 p.m. FM-C stated she heard RN-A yelling at P1 on 2/16/23 at around 4:15 p.m. FM-C notified FM-A and FM-B immediately to watch the video recordings to see what was going on with P1. FM-C was at P1s home the entire day of the 2/16/23. FM-C stated on 2/16/23 when she overhead RN-A yelling at P1, she opened the door and the curtain around his bed was closed. FM-C stated she offered RN-A if she needed assistance and RN-A denied the help. At around 5:30 p.m. FM-C received a call from FM-A and FM-B requesting that she check on P1 as they could see on the video RN-A was getting “flustered” with him again. FM-C went to his room and assisted RN-A this time without asking if she needed assistance. FM-C stated, “I saw what she did on the video, I was holding back tears and biting my tongue.” FM-C left the room but stayed close as she knew FM-A and FM-B were watching the video live and RN-As shift would be ending soon. Upon interview on 3/1/23, at 9:45 a.m. RN-C stated on 2/16/23, at about 7:30 p.m. as she was starting her onsite shift FM-A and FM-B notified her via telephone and told her they had watched video from the day shift, and they witnessed RN-A being physically rough and swearing at P1. RN-C stated she locked the door immediately in case RN-A returned and then called the agency administrator. RN-C stated P1 was agitated during her shift following the treatment by RN-A. RN-C stated she had to “calm him down” multiple times using multiple interventions. RN-C stated, “I have seen the abuse videos only because the family has shown them to me.” Upon interview on 3/1/23, at 12:18 p.m. LPN-B stated she had heard about RN-A being terminated. She stated RN-A often come in late, upsetting staff and expressed her frustrations about her home life in the presence of P1. LPN-B stated she had worked with P1 for 17 years and tried to assist RN-A by giving her tips on his cares but she most often she had to de-escalate her moods. Stating since December of 2022 RN-A’s frustrations had clearly gotten more pronounced, she was having marital problem and again LPN-B would try to give her support. On the days when there was not PCA RN-A would express complaints of exhaustion and hating her job in the presence of P1. Upon interview on 3/1/23, at 12:39 p.m. the Administrator stated she first heard about the complaint on 2/16/23, when RN-C called the facility stating FM-A and FM-B were going to fire RN-A and they would get in touch with the agency in the morning due to video footage that showed alleged abuse. The agency instructed RN-C to do a full nursing assessment. The Administrator stated she had not heard of any harm from RN-C. On 2/17/23, FM-A and FM-B called the administrator and stated they wanted RN-A off the case and described what they had visualized on the video. The Administrator reviewed the videos and had the case manager and human resources watch the video. RN-A was called and terminated. RN-A stated on the phone call that she was aware she was being taped and recalled how she treated him. She was accusatory towards the agency as she felt it was the agencies’ fault for not supporting her more. RN-A did not deny the abuse allegation. The Administrator stated the agency did not think to report this to the police but does consider it a crime. The agency policy titled Abuse Prevention Plan, dated 2022 indicated the purpose was to minimize the potential for abuse of any client, particularly those who are unable or unlikely to report abuse or neglect without assistance because of impaired mental, physical, or emotional status. Under the title Client assessment indicated the plan will address agency staff actions to address risk factors and plan will be communicated to all caregivers. If the client needs cannot be met safely with the home care plan of care, arrangements will be made to staffing (based on employee safety and available reimbursement) or facilitate a trans to a more supervised setting. The agency policy titled Identifying and Reporting Abuse/Neglect/Exploitation of Clients dated 2002 indicated Clients have the right to be free from mental, physical, sexual, and verbal abuse. All personnel providing service in the client’s home are mandated to report abuse of the vulnerable adult to the appropriate authorities. The policy defines verbal abuse as insulting, demeaning, disrespectful, oral, written, or gestured language directed toward and in the presence of the client. Mental abuse includes humiliation, harassment, and threats of punishment or deprivation (living in fear in one’s own home.) Physical abuse is defined as abuse perpetrated through any action intended to cause physical harm or pain, trauma, or bodily harm (e.g., hitting slapping, punching, kicking, pinching, etc.)

Participate in care CFR(s): 484.50(c)(4)(i,ii,iii,iv,v,vi,vii,viii) Participate in, be informed about, and consent or refuse care in advance of and during treatment, where appropriate, with respect to-- (i) Completion of all assessments; (ii) The care to be furnished, based on the comprehensive assessment; (iii) Establishing and revising the plan of care; (iv) The disciplines that will furnish the care; (v) The frequency of visits; (vi) Expected outcomes of care, including patient-identified goals, and anticipated risks and benefits; (vii) Any factors that could impact treatment effectiveness; and (viii) Any changes in the care to be furnished. This ELEMENT is not met as evidenced by: Based on interview and document review, the agency failed to ensure 3 of 3 patients (P1, P2 and P3) reviewed were offered to participate in the plan of care (POC) following the 60-day assessments performed by the agency registered nurses. P1's POC dated 1/28/23, indicated P1 had chronic respiratory insufficiency and was dependent on a ventilator. P1 had dysphagia (unable to speak), osteoporosis and chronic pain. The POC further indicated skilled nursing (SN) services 20-24 hours a day. Upon interview on 2/28/23, at 11:18 a.m. family member (FM)-A reported not being aware of when the agency does the 60-day recertification assessments. FM-A stated she only knows the assessment was completed when P1 receives a letter in the mail with the new assessment. FM-A stated she was not part of the care planning. FM-A stated an example was all the nurses all have different interventions for “calming” P1 down and some nurses will immediately use morphine for an interventions and other nurses will allow P1 to “cry out” for hours. She stated she would like more specifics on the POC. When she hears him crying out, she will approach the nurses and prompt them to give a medication intervention. FM-A stated years ago there used to care conferences regarding P1’s cares, but that is not the practice anymore. P2's POC dated 1/4/23, indicated P2 had chronic respiratory failure and was dependent on a ventilator. He was quadriplegic and had locked-in state (a rare nervous disorder, where patients are paralyzed except for the muscles that control eye movement), The POC further indicated P2 received SN services 8-24 hours per day 5-7 days per week. Upon interview on 2/28/23, at 2:49 p.m. FM-D stated she is not informed when P2’s assessments are being complete and has not been asked to participate with her input. She stated, “I don’t even know which staff RN’s and which staff are LPNs as the schedule does not indicate, I would assume an RN must do the assessment.” P3’s POC dated 2/5/23, indicated P3 had chronic respiratory failure and was dependent on a ventilator. P3 was quadriplegic and had muscular dystrophy (a condition that causes progressive and loss of muscle mass). The POC further indicated P3 had skilled nursing services 8-16 hours per day. Upon interview on 2/28/23, at 3:52 p.m. FM-E stated he was not certain about any agency assessments being done. FM-E stated, “The county nurses come out yearly and I converse with her about cares needed, but not the agency.” FM-E stated he was “under the impression” that the agency made their care plan from what the county allowed for services. Upon interview on 3/1/23, at 11:10 a.m. registered nurse (RN)-B, clinical care manger stated that during the 60-day recertification process the onsite RN’s receive notice when the assessment is due. The RN onsite performs the assessment in the agency software system. The clinical care manager reviews the assessment and any communication notes. The clinical care manager then processes the assessment report. The agency does not reach out to the patient or the family during the assessment. The family and/or patient has the agencies contact information and the agency does a yearly satisfaction survey for any needs patients/family may have. The patient is sent a copy of the new assessment and an updated medication profile list following completion of the assessment. Upon interview on 3/1/23, at 11:39 a.m. the Administrator stated, “There should be communication with the patient or family with the assessments.” The agency policy titled Client Reassessment/Update of Comprehensive Assessment dated 2022, indicated clients are reassessed to determine their response to care. The agency policy titled Comprehensive Client Assessment dated 2022, indicated the purpose of the assessment is to make care, treatment or service decisions based on information developed about each client’s needs and the individual’s response to care. The assessment strategies included: interview, interaction, direct observation, inspection, clinical measurements, clinical reasoning and MD or facility information.

Investigation of complaints CFR(s): 484.50(e)(1) Standard: Investigation of complaints. The HHA must-- This STANDARD is not met as evidenced by: Based on interview and document review, the agency failed to comprehensively investigate an allegation of mental, physical, and verbal abuse for 1 of 1 patient (P1) reviewed who had video evidence that registered nurse (RN)-A yelled profane language and physically hit P1. P1's POC dated 1/28/23, indicated P1 had chronic respiratory insufficiency and was dependent on a ventilator. P1 had dysphagia (unable to speak), osteoporosis and chronic pain. The POC further indicated skilled nursing (SN) services 20-24 hours a day. The agency Client Complaint/Grievance Report dated 2/17/23 indicated the reason for the complaint was inappropriate treatment of P1 by RN-A on 2/16/23 day shift. P1’s family called to report an incident occurring at their home during RN-A’s shift on 2/16/23. The family reported the video showed both verbal and physical aggression by RN-A. The family will share the video with the agency Administrator. The steps taken to investigate the complaint was the video footage shared by the family was reviewed. The results of the investigation were to terminate RN-A, Minnesota Adult Abuse Reporting Center (MAARC) report will be filed, and a report will be sent to the Minnesota Board of Nursing. Incident Report Form dated 2/17/23 description of the incident was video surveillance of nurse’s shift showed physically aggressive care. Verbally inappropriate statements and reactions to client’s cares and needs during the shift. Witnesses included video surveillance in P1’s home. Description of injures indicated no noted injures. RN-C completed a detailed head-to-toe assessment following the day shift incidents. Follow-up action included the family spoke with the administrator following the review of the video surveillance. RN-A was terminated, MAARC report was completed and the report to the Minnesota Board of Nursing to follow. Upon interview on 2/27/23, at 10:35 a.m. FM-B stated the only correspondence he had with the agency was the day he and FM-A reported the incident. An email from the administrator came a week later indicating reports had been made to the state of Minnesota and RN-A was terminated. FM-B denied any interview with agency regarding any other staff members, any prior concerns with RN-A and any follow-up regarding P1’s status. Upon interview on 2/27/23, at 3:10 p.m. FM-A stated she had not heard from the agency since the reported the incident other than an email dated 2/23/23, that stated the agency resolved the complaint by terminating the nurse. FM-A stated she was aware RN-C did a full skin assessment on 2/16/23, following the complaint. FM-A denied any formal interviews with or updates from the agency. Upon interview on 2/28/23, at 12:55 p.m. a personal care attendant (PCA) from another home health care agency who has worked with P1 for 18 years stated she had multiple shifts working with RN-A since 2021. The PCA stated she had not been interviewed by the home care agency regarding the abuse allegation. Upon interview on 2/28/23, at 4:07 p.m. FM-C stated she heard RN-A yelling at P1 on 2/16/23. FM-C notified FM-A and FM-B immediately to watch the video recordings to see what was going on with P1. FM-C was at P1s home the entire day of the 2/16/23. FM-C denied any contact with the agency at the time of the allegation or having any part of an agency investigation. Upon interview on 3/1/23, at 9:45 a.m. RN-C stated on 2/16/23 about 7:30 p.m. as she was starting her onsite shift with P1, FM-A and FM-B notified her via telephone and told her they had watched video from the day shift, and they witnessed RN-A being physically rough and swearing at P1. RN-C stated she locked the door immediately in case RN-A returned and then called the agency administrator. RN-C was given instruction by the administrator to do a head-to-toe body assessment and to document any concerns. RN-C told the administrator FM-A and FM-B would be calling the agency the following morning to file a report. RN-C denied any other instruction given by the agency on the night of 2/16/23. There was mental assessment completed. RN-C denied any interviews following the allegations and has not been given additional education. RN-C stated, “I have seen the videos only because the family has shown them to me.” Upon interview on 3/1/23, RN-B the clinical manager stated that RN-C was told to do a skin assessment the night of the allegations. She denied any other recommendations given to the nurse, no pain assessment, no mental health assessment, and no follow-up assessments in the following days. RN-B denied any interviews with nursing staff and other clients. She was not aware if the agency reviewed and made changes to any policies or had a plan to do any education with the agency staff. She stated, “we do yearly abuse training, and the families have a yearly satisfaction survey, so we would know of any concerns on that survey.” RN-C was not certain if the yearly satisfaction survey were patient specific, so the agency could identify which patient had a concern. Upon interview on 3/1/23, at 11:39 a.m. the Administrator stated she was not aware if P1 had any physical or mental changes since the incident, other than no bruising on 2/16/23. No follow-up assessments were issued to the staff. “It is my expectation that any changes would be noticed and reported.” The administrator denied interviewing nursing staff who worked with RN-A, the PCA who worked frequently with RN-A, FM-C who was at the home all day on 2/16/23, or any other residents. She denied policy review of any further education for the nursing staff. A police report was not filed. The agency's vulnerable adult policy titled Identification and Reporting Suspected Maltreatment revised 1/17, indicated the internal review and investigation must include the following: whether related policies and procedures were adequate; whether this was like past events with the patient or services involved; and whether there was a need for corrective action to protect the health and safety of vulnerable adults. A facility policy titled Client/Family Complaint/Grievance Policy dated 2022 did not indicate how the facility conducts an investigation. A facility policy regarding agency investigations was requested however none were received.

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 observation, interview, and document review, the agency failed to conduct a comprehensive assessment that accurately reflected the patient's status for 1 of 3 patients (P1) reviewed when agency staff were setting-up P1’s liquid medications in syringes for the family to administered without a physician order or specific nursing instructions for the set-up. P1's plan of care (POC) dated 1/28/23, indicated P1 had chronic respiratory insufficiency and was dependent on a ventilator. P1 had dysphagia (unable to speak), osteoporosis and chronic pain. In addition, the POC indicated skilled nursing services 20-24 hours a day. Skilled nursing interventions included: 1. Change tracheostomy tie daily. 2. Actual temp = subtract 0.8 from temporal temperature, add 1.1 to axillary temperature and subtract 1.0 from rectal temperature. 3. Adjust heat levels on mattress as needed to maintain a comfortable temperature. 4. Administer Carafate per gastrostomy tube (g-tube) 1 hour prior to feeding. 5. Administered chest physiotherapy twice daily for 15 minutes after nebulizer and as needed, follow with sterile suctioning. 6. Air mattress on bed. 7. Ambu bag as needed. 8. Apply warm congresses to eye twice daily and as needed. 9. Assess for signs and symptoms of a urinary tract infection. 10. Assess for suspected patient neglect and or abuse. 11. Assess function of indwelling catheter and drainage systems 12. Asses gastrointestinal status including bowel sounds, abdomen, and bowels elimination patterns every shift. 13. Assess oxygen saturation continuously. 14. Assess risk factor for skin breakdown. 15. Assess tracheostomy. 16. Assess urinary function. 17. Assess secretions. 18. Attempt to play his music. 19. Call M.D. at first signs of potential fracture/pain. 19. Call respiratory therapy to troubleshoot ventilator. 20. Change ambu bag every 6 months. 21. Change foley catheter weekly and as needed. 22. Change g-tube every 1-2 months and as needed, administer all medication via g-tube 23. Check gastrointestinal residuals. 24. Check placement of all wheelchair straps. 25. Client answers “yes” or “no” and makes choices by moving his head to right for yes and to the left for no. 26. Choices are made the same way by moving his head. 27. Client has leaking around his g-tube at times, do not position on his left side of stomach. 28. Client is MRSA positive precautions must be followed with nursing nurses wearing gloves and masks per procedures. 29. Client will be transferred with assist of two and the ceiling life. 30. Client will have consistent caregivers as often as possible. 31. Compression socks up to 8 hours as tolerated. 32. Confirm all setting/parameters on ventilator and humidifier as ordered by the physician. 33. Cool with tepid bath when temperature is >101.5 rectally. 34. Cover with heated water blankets and/or heated mattress if temp 98.5, cover with down blanket if temperature 95-96. 57. Remove clothes and take rectal temperature when temperature is >100.3. 58. Reposition client every 1-2 hours. 59. Respiratory distress plan (with instructions). 60. Sage mouth wash daily. 61. Say “No” firmly when client is exhibiting self-injurious behaviors. 62. Sterile tracheal suctioning with respiratory treatments. 63. Stool Guaiac test as needed for pink stools. 64. Terminal bleeding plan (with instructions). 65. Monitor closely for trach decannulation. 65. Use covered ice pack for rectal temp >102.5. 66. Vent g-tube every 6 hours when bloated. 67. Vitals blood pressure – weekly and as needed, temperature regularly. The interventions do not indicate skilled nursing to set-up medication syringes and instructions for family to administrate when agency does not provide skilled nursing services. Upon observation on 2/28/23, at 11:18 a.m. family member (FM)-A was providing cares for P1 along with a home health aide (HHA) from another home care agency from 7:00 a.m. until 7:00 p.m. On a cart with locked drawers the liquid medications for P1 were already drawn-up in syringes for FM-A to administer. Each syringe had a sticker with the medication name and time to be given, no further instructions given. The drawn-up syringes included seven medications: 1. One syringe of amitriptyline for p.m. use. 2. One syringe of clonazepam for p.m. use. 3. One syringe of depakene for p.m. 4. Two syringes of diazepam to be used as needed. 4. One syringe of Melatonin for p.m. 5. Three syringes of morphine to be used as needed. 6. Four syringes of Neurontin to be used as needed. 7. Three syringes of Tegretol to be used as needed. Upon interview on 2/28/23, at 11:35 a.m. FM-A stated the nurses set-up medications for her to administrate when the agency does not have skilled nursing staff. FM-A stated she does not know what each medication is for, however she is aware of which medication is for pain and which medication is for agitation. FM-A stated she has questioned if the medications set-ups were complete as she did not have a medication list with times until just this morning 2/28/23. The overnight licensed practical nurse (LPN)-A brought a printed medication profile and wrote in the times to administer the medications. FM-A stated the agency has never communicated a “formal plan” for medication set-up. FM-A stated she asks the attending nurse prior to end of their to fill medications for the family when they cover P1’s cares. In addition, FM-A stated she does not have access to P1’s medications to read the labels on the bottles. Upon interview on 3/1/23, at 10:54 a.m. LPN-A stated that she has set-up medication syringes for the family for many years. LPN-A stated the medications are labeled with the medication name and the time to be given only. There is no documentation that medications were being set-up or specific instruction on how and when for medication set-up. She stated she did provide a copy of the medication profile on 2/28/23 and hand wrote in the times to be given for the family to have on file. “Setting up the syringes is just something we do.” LPN-A was not aware whether the case manager knew the medications were being set-up or not. LPN-A confirmed the medication set-up was not on the POC. Upon interview on 3/1/23, at 11:10 a.m. registered nurse (RN)-A the clinical manager stated she was aware the staff was setting up the medication syringes. RN-A confirmed the medication set-up with instructions was not on the POC. RN-A stated the family does receive a medication profile in the mail with every 60-day recertification assessment. RN-A stated the medication profile does not identify specific times on the form. RN-A stated recently she has instructed the nursing staff to write times on all the medication profiles in the home when they arrive in the mail RN-A was not certain if P1’s nurses had completed writing the times on his medication profile. Upon interview on 3/1/23, at 11:39 a.m. the Administrator stated that any cares and interventions should be on the POC. She also stated every family has a medication profile sent to their home with every re-certification, but she was not certain what education the nurses onsite were doing with the medication profiles. A facility policy titled Medication Management dated 2022, indicated if there are other health care organizations in providing services in the home, the medication profile will be made available to them. Family members or other support individuals that may assist with administering or obtaining medications from the pharmacy will be oriented to the plan. Clients/family members will be educated about proper medication storage in the home as needed. If the client is receiving intravenous feeding and/or medications, storage and administration guidelines will be reviewed in the home with client/caregivers. If specific mediations or solutions are needed to prepare mediations, these must be accurately labeled with contents, expiration dates and warnings, as necessary. If medications are being set-up by the nurse for self-administration or administration by family or other caregivers, a chart or other form of direction should be left in the home to assure medications are taken at the times ordered, and to assess client compliance with the schedule.