Every finding on record at Hiram Certified Home Care Company

The following statement of deficiencies represents the results of a partial extended re-certification survey of Acacia Certified Home Health Agency conducted on 07/12/2023 through 07/19/2023. A standard re-certification survey was initiated on 07/12/2023. Deficient practices were identified within Level 1 standards in Conditions 484.60 (Care planning, coordination of services, and quality of care) and 484.80 (Home health aide services) resulting in a partial extended survey. The survey consisted of a review of 13 clinical records including 5 discharge records, 9 personnel records, 1 contract and 5 observational home visits. The survey included a review of pertinent policies and procedures, Quality Improvement meeting minutes for the past 12 months, agency Admission Packet, the Emergency Preparedness Plan, and Complaint Log. Pre-survey activities consisted of review on 07/11/23 of the agency’s Health Commerce System account, Internet Quality Improvement and Evaluation System (iQIES) reports for the period 04/2022-03/2023, and the agency’s compliance with report submission for the 2021 statistical report. The Director of Patient Services, Clinical Manager and staff were interviewed. Findings were reviewed at the exit conference on 07/19/2023. The following deficiencies are identified as a result of the survey: Federal: G 526 Content of the Comprehensive Assessment, G 574 Plan of Care Must Include the Following, G 606 Integration of All Services and G 798 Home Health Aide Assignment and Duties

Content of the comprehensive assessment CFR(s): 484.55(c) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: This STANDARD is not met as evidenced by: Based on a review of clinical records, and interviews with the Director of Patient Services (DPS), it was determined in 3 of 13 records (patients # 3, 9 and 11) the agency failed to ensure comprehensive assessments were of sufficient scope to determine all patient needs were identified. Evidence as follows: Patient # 11 was admitted to the agency on 01/06/23 with diagnoses of colostomy, abdominal surgical incision, neuropathic bladder with supra pubic catheter, and type 2 diabetes. The SN failed to perform a complete and/or accurate assessment of the patient's needs. Colostomy On 01/06/23 the SN documented in the initial assessment the patient had a new colostomy (surgical opening to bowel) to the left lower abdominal quadrant. The with stoma (surgical opening) was beefy red, moist and with soft brown stool. The note included the patient correctly demonstrated colostomy change and stoma site care. On 07/18/23 the surveyor requested the agency policy for colostomy management. The DPS provided a policy titled "Digestive Colostomy/Ileostomy Appliance Application" reviewed 01/2023. The policy and included instructions to obtain stoma size measurement due to new colostomy stoma size changes occur up to 3 months after surgery. The SN failed to assess stoma size and amount of stool output. Supra Pubic (SP) Urinary Catheter On 01/06/23 the SN documented the patient had an 18 French SP urinary catheter with a 5-10 ml balloon with clear urine in drainage bag. The SN failed to assess the amount of urine output, catheter insertion site and type of site care needed and person responsible for providing care. Diabetes The 01/06/23 plan of care included the following: SN assess fasting blood sugar every visit. Patient to test blood sugar 3 times per day and notify the agency for blood sugar less than 70 or greater than 250. On 01/06/23 the SN documented in the initial assessment the patient has type 2 diabetes and 3 times a day. The note included the patient’s non-fasting blood sugar level was 152 and was not taking insulin or oral hypoglycemic medications. The SN failed to assess blood sugar ranges and patient blood sugar testing times such as before meals or at bedtime to determine blood sugars were within ordered parameters and patient was performing non fasting blood sugars as ordered. The record was reviewed on 07/19/23 at 11 a.m. with the DPS. She acknowledged the findings, and no additional information was provided. Home Visit Patient # 3 was admitted to the agency on 07/03/23 with diagnoses of osteomyelitis of the right tibia and fibula, acute posthemorrhagic anemia and hypertension. The SN failed to perform comprehensive assessments of the patient's needs. Wound Care On 07/14/23 the SN obtained new wound care orders to right tibia as follows: clean wound gently patting with saline moistened gauze do not irrigate or wash, apply a piece of durafiber AG to wound bed, cover with sterile gauze, secure with rolled gauze apply tubigrip to right lower leg, change daily. SN visit 3 times per week for wound care, SN to teach care giver to perform on non-skilled SN days. On 07/14/23 at 10:00 a.m. the surveyor conducted an observational home visit with the SN The SN informed the care giver of the order changes and stated the SN was going to do the wound care. During the wound care procedure, the SN provided verbal instructions to the care giver, however; the SN failed to assess the care giver's ability to perform wound care by verbal teach-back or return demonstration to assess the care giver's understanding or need for additional teaching. The record was reviewed on 07/18/23 at 12:00 p.m.with the DPS. She acknowledged the findings, and no additional information was provided. Patient # 9 was admitted to the agency on 05/19/23 with diagnoses of fractured right femur, end stage kidney disease, type 2 diabetes and heart failure. The skilled nurse (SN) failed to perform a complete and/or accurate assessment of the patient's needs. Dialysis On 05/19/23 the physical therapist (PT) completed the initial assessment. The PT documented the patient was on dialysis and had a central venous catheter to the right chest and peritoneal dialysis. The note included the patient was managed by dialysis center and the agency SN was to evaluate hemodialysis catheter and peritoneal dialysis site. On 05/19/23 the SN visited the patient. The SN documented the patient's genitourinary system was within normal limits (WNL). There was no assessment of urinary output, voiding pattern, characteristics of urine or patient's dependence on dialysis. There was no SN assessment of whether the patient had either a central venous catheter or an abdominal/peritoneal catheter in place to perform dialysis. On 05/25/23 the SN documented the physician was notified the patient's leg circumference increased by 5 cm. The physician's office directed the SN to contact the dialysis center due to the patient getting less dialysate output than what was instilled. The SN documented the patient's care giver called the dialysis center and was instructed by the dialysis nurse to use a stronger dialysate solution. The SN failed to assess: -type of dialysis performed (hemo/peritoneal) -dialysis frequency -person responsible to perform procedure -type and amount of dialysate solution -catheter/site care and person responsible Edema The 05/19/23 plan of care included the following instructions for monitoring edema (fluid retention): measure bilateral lower extremity circumference at the following areas weekly and notify the physician for a 3 cm or greater increase: instep at foot dorsum, ankle 1 inch above lateral malleolus and calf 6 inches below center patella. On 05/19/23 the SN documented the patient had trace edema to the right leg and 2+ in the left leg. The note included the following baseline measurements: R 27, 30, 39 and L 31, 34, 43. The SN failed to include the anatomical positions (instep, ankle calf) measurements were obtained to ensure accuracy and consistency for monitoring and reporting changes. Pain The 05/19/23 plan of care included the patient was to take Tylenol (pain reliever) 1000 mg every morning and Norco 10/325 mg (narcotic/Tylenol pain reliever) 2 tablets every 6 hours as needed (PRN) maximum daily dose 8 tablets and report pain of 8 or greater to the physician. On 05/19/23 the SN documented the patient had constant pain with intensity of 8/10 on 0-10 pain rating scale to the right hip and lower back and takes Norco for pain management. The SN failed to perform a complete pain assessment to include: -physician notification of pain level 8/10 -best/worst pain intensity past 24 hours -frequency/amount/time last dose routine/PRN medication taken -non-medication measures used for pain relief -effectiveness patient satisfaction with pain management Bowel Management The 05/19/23 plan of care included the following: no added salt, no concentrated sweets with fluid restricted to 1500 ml/day and take Senokot 8.6/50 mg 1 tablet daily PRN maximum daily dose 1 tablet. On 05/19/23 the SN documented the patient had not had a bowel movement in 5 days. The note included the patient takes Senokot (laxative). The SN instructed the patient to eat grapes, drink water and prune juice. There was no assessment of Senokot frequency, amount or when last dose was taken. The SN failed to assess and determine dietary and fluid interventions provided to the patient for bowel management were appropriate and consistent with the patient's ordered diet and fluid restrictions. On 07/18/23 at 12:00 p.m. the record was reviewed with the DPS. She acknowledged the findings, and no additional information was provided.

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 a review of clinical records, and interviews with the Director of Patient Services (DPS), it was determined in 4 out of 13 records (patients # 4, 6, 9 and 10), the agency failed to develop individualized plans of care that were complete, accurate, and addressed the total needs of the patients. Evidence as follows: Home Visit Patient # 6 was admitted to the agency on 06/30/23 with diagnoses of pulmonary embolism, history of aspiration pneumonia, enlarged prostate, and neurogenic bladder. The 06/30/23 referral information included a 06/28/23 Occupational Therapy (OT) evaluation. This included “straight cath PRN”. On 06/30/23 the PT visited the patient for the initial assessment and documented the patient had a history of urinary incontinence, BPH and a neurogenic bladder. The PT documented the patient had a catheter with no further details, the box was checked to urine with no further details. Incontinence was checked but patient requires a urinary catheter was not checked. The PT documented the SN was visiting the next day to assess skin issues from lines in the hospital and to provide medication education. The PT documented conferencing with the DPS regarding the patient visiting the ED on 06/28/23 with blood in urine, and an 18 Fr Foley (indwelling) catheter was placed and remained in place. On 07/01/23 the SN visited the patient and documented the 18 Fr Foley was draining clear yellow urine. The SN updated the plan of care to include the 18 Fr catheter with a 5-10 ml balloon and to change the catheter every 4-6 weeks and as needed for plugged or leaking catheter, as well as irrigating with 30 ml of normal saline or sterile water if plugged or leaking. The update failed to include instructions regarding catheter care and frequency. On 07/11/23 the SN visited the patient and documented the Foley was removed at the MD appointment on 07/07/23, and no urinary issues were reported. On 07/11/23 the SN obtained a verbal order effective 07/07/23 discontinuing Foley and Foley care orders due to Foley removed and discontinued by the urologist on that date. On 07/13/23 at 10 a.m., the surveyor conducted an observational home visit with the SN. During the visit the SN discussed the removal of the urinary catheter on 07/07/23 and current urinary status, inquiring if there were any signs or symptoms of infection and how the patient was urinating. The patient’s daughter stated regarding the catheter the patient was using “different ones he uses for himself”. Following the visit, the surveyor interviewed the patient and family. The surveyor asked them to clarify what was meant by the above comment and was informed the patient performed self-catheterization 3-4 times per day and has done this for 10-15 years. They stated the urologist provided the catheters and presented several 14 Fr catheters. The surveyor asked if the nurse had ever observed the patient performing self-catheterization, and they stated no. The plan of care failed to include the straight catheters and there was no evidence the agency was aware of the patient history of requiring self-catheterization for urinary elimination. On 07/18/23 at 12 p.m. the record was reviewed with the DPS. On 07/19/23 at 09:10 a.m. the DPS stated the agency was not aware the patient required self-catheterization. Patient # 4 was admitted to the agency on 06/14/23 with diagnoses of pseudoaneurysm of femoral artery repair, hypertension, atrial fibrillation and stroke. The patient was a resident of an Assisted Living Program (ALP). On 06/14/23 the SN visited the patient for the initial assessment and documented the patient had a surgical incision to the right groin and the patient’s daughter demonstrated competency with performing the dressing change. The SN documented a surgical incision to the right groin measuring 10 cm long x 0.6 cm wide with 13 sutures. The SN documented speaking to facility staff with the daughter present, however, evidence was lacking the SN collaborated with staff of the ALP to instruct regarding care to the site including what to do regarding showering/bathing. The 06/14/23 plan of care included the following wound care: using clean technique apply a non-adherent pad every day and secure with tape. The plan failed specify who would be performing wound care. The orders were for the SN to visit 2 times a week for 2 weeks, 1 time weekly for 3 weeks, and 4 PRN visits. The plan of care failed to include instructions regarding bathing/showering with the wound. On 07/18/23 at 12 p.m. the surveyor reviewed the record with the DPS who acknowledged the findings, and no further information was provided. Patient # 9 was admitted to the agency on 05/19/23 with diagnoses of fractured right femur, end stage kidney disease, type 2 diabetes and heart failure. The 05/19/23 plan of care was incomplete for the following: Dialysis On 05/25/23 the SN documented in a visit note the patient had decreased output following instillation of dialysate solution. The patient's care giver stated the dialysis center was notified and instructed the care giver to use a stronger dialysate solution. The 05/19/23 plan of care failed to include the following: -identification of the type of dialysis performed (hemodialysis/peritoneal) -access catheter type, size and location -procedure frequency -person responsible to perform procedure -catheter/site care and person responsible -type and amount of dialysate solution BiPAP On 05/19/23 the SN documented in the initial assessment the patient used BIPAP (bilevel positive airway pressure) at night setting 9/4. The 05/19/23 plan of care failed to include BiPAP with instructions for use and machine settings. On 07/18/23 at 12:00 p.m. the record was reviewed with the DPS. She acknowledged the findings, and no additional information was provided. Patient # 10 was admitted to the agency on 08/17/22 with diagnoses of bladder cancer, type 2 diabetes and irregular heartbeat. The 08/17/22 plan of care was incomplete for the following Diabetes Management The 08/17/22 plan of care included instructions for the patient to test blood sugar 3 times per day and report blood sugar less than 70 or greater than 250. The plan failed to specify if blood sugar testing was fasting/non-fasting and include specific times the patient was to test blood sugar such as before a meal or at bedtime. On 09/15/22 the SN visited the patient and documented the patient's care giver was educated on new insulin order. The note included the SN instructed the care giver to keep fast acting glucose such as icing or honey in the home. The care giver stated she bought cake frosting that morning due to the patient having recent episodes of low blood sugar. The SN failed to consult with the physician for a plan with instructions to treat low blood sugar. On 07/18/23 at 12:00 p.m. the record was reviewed with the DPS. She acknowledged the findings, and no additional information was provided.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on a review of clinical records and interviews with the Director of Patient Services (DPS), it was determined in 3 of 13 records (patients # 7, 10 and 12) the clinicians failed to effectively coordinate patient care. Evidence as follows: Patient # 12 was admitted to the agency on 02/05/23 with diagnoses of advanced lung cancer, recent COVID-19 infection with pneumonia, chronic obstructive pulmonary disease, history of pulmonary embolism, and urinary tract infection. The agency failed to coordinate care to ensure all needs were met. Assistance with use of Mechanical Lift/Aide Service On 02/05/23 the SN visited the patient for the initial assessment and documented the family assisted with activities of daily living, the patient was entirely dependent, had a catheter for urinary elimination, was incontinent of bowel, bedbound and required a Hoyer (mechanical) lift to transfer. The patient’s spouse was providing 24/7 care and requested education on using the Hoyer lift. The physical therapy (PT) and occupational therapy (OT) evaluations were pending. There was no evidence the SN discussed or offered HHA services or a social work referral to obtain assistance in the home. The SN failed to expedite a therapy visit to provide education regarding the lift. On 02/06/23 the SN documented the spouse called the office and expressed concerns regarding using the Hoyer lift and transferring the patient to the wheelchair and did not know how to use it. The SN stated PT and OT was scheduled that week. On 02/07/23 the PT visited to evaluate the patient and documented the patient required a Hoyer lift, wheelchair and assist of 2 to safety leave the home, and lived with spouse who is his sole caregiver. There was no discussion of the possible need for additional assistance in the home. On 02/08/23 the SN documented a SOC case conference note the plan was for nursing 2 times weekly for 2 weeks, 1 time weekly for 3 weeks, and 4 PRN. Other services ordered were PT and OT. There was no documentation regarding spouse being the sole caregiver and whether help may be needed in the home. On 02/09/23 the OT visited for an evaluation and documented the goal to improve bed mobility using the Hoyer lift. The OT documented the patient required total assist with activities of daily living and transfers and 24/7 care was provided by the spouse. Skin Changes On 02/05/23 the SN visited the patient for the initial assessment and documented the patient had a wound to the right 1st toe. The SN also documented preventative wound care to the upper back and sacrum due to significant weight loss and bony prominences. The 02/05/23 plan of care included a foam dressing to back twice weekly. Other preventative measures the plan included a hospital bed turning and positioning every 2 hours. On 02/14/23 the SN documented a phone call from the spouse reporting a new wound to the patient’s back. The SN documented she spoke with the licensed practical nurse (LPN) who would see the patient for a SN visit and “assess” the new wound. The SN failed to recognize the LPN was not qualified to perform an assessment visit for the new problem. The responsibility of patient assessment is outside of the scope of practice for LPNs per Section 6902 of Article 139 of the NY State Education Law. This is clarified by the New York State Education Department information regarding Practice Information "The Differentiated Scope of Practice of Licensed Practical Nurses (LPNs)and Registered Professional Nurses (RNs)" which clarifies that assessment is not within the privilege of an LPN, and that the roles of RN and LPN are not interchangeable. http://www.op.nysed.gov/prof/nurse/nurse-scope-lpn-rn.htm. On 02/14/23 at 10:30 a.m. the LPN visited the patient and documented the patient had a new wound to the sacral area 0.4 x 0.3 x 0.1 cm that was a stage 2 pressure ulcer to the sacral area and reported to the RN and MD to obtain orders. The LPN cleansed the wound with normal saline, applied solosite wound gel and covered with a foam dressing. The RN failed to assess the wound and coordinate care to ensure the plan of care met the needs of the patient. Oxygen On 02/05/23 the SN visited the patient for the initial assessment and documented the patient was not using oxygen and had an oxygen saturation (sat) of 94% on room air. On 02/09/23 the LPN visited the patient and documented the O2 sat was 90% on room air. On 02/12/23 the SN documented receiving a telephone call from the spouse who stated the patient was short of breath (SOB), the oxygen saturation level kept dropping and was up to 88% with oxygen on. The SN offered a visit to assess the patient which the spouse declined. The SN failed to determine the amount of oxygen the patient was using and recognize there was no order for oxygen in the home. On 02/13 23 the SN visited the patient and documented the patient had a new non-productive cough with congestion. The SN documented lung sounds were absent throughout. The oxygen saturation level was 91 % on room air. The SN documented speaking to the MD office prior to the visit and reported decrease in SaO2 along with worsening SOB and after the visit to request Hospice referral. It was unclear if oxygen was in the home as documented on 02/12/23 or that it was offered or requested. The patient and spouse declined ED eval and discussed Hospice consult. On 02/15/23 the patient transferred to Hospice. On 07/18/23 at 12 p.m. the record was reviewed with the DPS. On 07/19/23 at 09:10 a.m. The DPS stated she did not have an explanation regarding oxygen and no further information was provided. Patient # 7 was admitted to the agency on 06/16/23 with diagnoses of polymyositis with myopathy, high blood pressure and type 2 diabetes. The clinicians failed to coordinate care to ensure patient needs were met. The 06/16/23 plan of care included Tylenol 500mg 2 tabs by mouth every 8 hours as needed for pain maximum daily does 3000mg. On 06/30/23 the physical therapist (PT) visited the patient. The PT documented the patient stated she was taking Advil ( non-steroidal pain medication) for pain. The PT instructed the patient to take Tylenol as ordered in the plan of care.There was no evidence the PT coordinated care with the physician or SN regarding a plan for effective pain management including obtaining orders with instructions for the patient to take Advil for pain. On 07/07/23 the PT documented the patient reported taking Advil that morning for moderate pain at 5/10 on a 0-10 pain rating scale. The note included in addition to Advil, the patient wanted to try taking Zyrtec (decongestant ) for sinus congestion/pressure relief. The PT documented the SN was made aware and would clarify with the physician. On 07/07/23 the SN visited the patient. The SN documented the patient denied pain but stated sinus pressure continued. The SN phoned the physician’s office and obtained verbal orders for new wound care and SN visit frequency, however; there was no evidence the SN coordinated a plan for pain management including clarification to use Advil or obtain a new order for Zyrtec to treat sinus congestion. On 07/18/23 at 12:00 p.m. the record was reviewed with the DPS. She acknowledged the findings, and no additional information was provided. Patient # 10 was admitted to the agency on 08/17/22 with diagnoses of bladder cancer, type 2 diabetes and irregular heartbeat. The SN failed to coordinate patient care as follows: On 08/29/22 the SN visited the patient. The SN documented the patient reported having had a choking episode the previous day and the care giver stated the patient choked/coughed regularly when drinking. During the visit the SN observed the patient coughed persistently when drinking iced tea. The SN educated the care giver on signs and symptoms of aspiration. The SN called the physician's office and documented leaving a detailed message regarding the change in condition including alerting the physician the agency provides speech therapy if the physician orders a referral. On 08/30/22 the SN completed a PRN visit. The patient's care giver requested the SN visit the patient to assess lethargy and decreased alertness. The care giver reported the patient continued with coughing and choking when drinking fluids. The SN taught the patient to use the chin tuck technique for swallowing and instructed the care giver to discontinue using straws with fluids, thicken liquids with a thickener and follow up with the physician regarding speech evaluation and swallow study. There was no evidence the SN contacted the physician's office to coordinate a plan for the speech evaluation/swallow study, aspiration precautions and orders to thicken liquids. On 09/06/22, 09/14/22 and 09/15/2 the SN visited the patient. The SN documented at each visit the patient continued to have difficulty with swallowing and choking on liquids. There was no evidence the SN followed up with the physician to coordinate a plan for: -aspiration precautions -thickening fluids/diet modifications -referral for speech evaluation/swallow study On 07/18/23 at 12:00 p.m. the record was reviewed with the DPS. She acknowledged the findings, and no additional information was provided.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on clinical record review of 2 patients receiving home health aide (HHA) services (patients # 9 and 10), and interviews with the Director of Patient Services (DPS), it was determined in 2 of 2 records the agency failed to ensure the clinicians developed complete and accurate aide written instructions. Evidence as follows: Patient # 9 was admitted to the agency on 05/19/23 with diagnoses of fractured right femur, end stage kidney disease, type 2 diabetes and heart failure. The aide care plan developed on 05/19/23 by the Occupational Therapist (OT) was incomplete for the following: Fluid Restriction The 05/19/23 plan of care included the patient's fluid intake was restricted to 1500 ml/24 hours. The aide care plan failed to include instructions alerting the aide the patient was limited to oral intake of 1500 ml/24 hours. Edema On 05/25/23 the SN documented the patient had 3+ pitting edema to bilateral lower extremities and was educated on signs and symptoms of heart failure and instructed to elevate legs as often as possible. The SN failed to update the aide care plan to include instructions for edema management including elevating legs and signs and symptoms the aide should observe for and report to the SN. Bowel Management On 05/19/23 the SN documented in the initial nursing assessment the patient's last bowel movement was on 05/14/23 (5 days). The note included the patient had a history of constipation, was on a narcotic pain medication that can cause constipation, and used Senokot (laxative) for bowel management. The SN failed to ensure the aide care plan included instructions for the aide to record and report lack of bowel movement or signs and symptoms of constipation to the SN. On 07/18/23 at 12:00 p.m. the record was reviewed with the DPS. She acknowledged the findings, and no additional information was provided. Patient # 10 was admitted to the agency on 08/17/22 with diagnoses of bladder cancer, type 2 diabetes and irregular heartbeat. On 09/01/22 the plan of care was updated to include HHA service 2 times per week for 1 hour for personal care. The aide care plan developed by the OT was incomplete for the following: Bathing The aide care plan included the patient was to have both a partial/sponge bath and a shower at every visit. The OT failed to provide specific instructions for which method of bathing was appropriate for the patient and/or when the patient should have a sponge bath instead of a shower, leaving it up to the aide to decide. Bleeding Precautions The 08/17/22 plan of care included Plavix 75 mg (a blood thinner) daily. The OT failed to include bleeding precautions with signs and symptoms the aide was to observe for and report to the SN. Aspiration Precautions On 08/30/22 the SN documented the patient's caregiver reported the patient was choking on thin liquids and the caregiver was instructed to thicken liquids with thickening agent. The 09/01/22 aide care plan failed to include aspiration precautions or instructions for thickening liquids. On 07/18/23 at 12:00 p.m. the record was reviewed with the DPS. She acknowledged the findings, and no additional information was provided. Failure to ensure that home health aide care plans are complete has the potential for unmet patient needs.