Every finding on record at Ick-Assurance Home Heatlh Care Inc

A Recertification survey was conducted at ICK-Assurance Home Health Care Inc., located at 960 South Street, Floor 2, Fitchburg, MA., 01420, on January 16, 2026, and January 20, 2026, for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at ICK-Assurance Home Health Care, Inc., located at 960 South St., Floor 2, Fitchburg, MA., 01420, on January 16, 2026 and January 20, 2026, for compliance with CFR Part 484 Requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

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 record review, policy review and interview, the agency failed to ensure a patient participate in, was informed about, and consented or refused care in advance of and during treatment, where appropriate, for 2 patients (#4 and #7), out of a total sample of 7 patients. Findings include: 2. Patient #7 was admitted to the agency in June 2025 with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition when the body cannot use insulin correctly and sugar builds up in the blood). Review of the clinical record indicated the initial start of care visit was completed on 6/20/25. Further review of the clinical record did not contain any signed consent documentation that would have been provided and reviewed upon admission. During an interview on 1/16/26 at 3:50 P.M., the Administrator said there was no signed admission consent, as required. Review of the agency's policy entitled, Admission Documentation/Patient Education, dated May 2025-2026, indicated the following: *Upon admission to the agency, certain documentation will be provided to, explained and reviewed with, and signed by the patient and by the admitting clinician. *Only the admission document sign off sheet with the patient's signatures evidencing that each of the documents listed below were reviewed with the patient, shall be brought back to the patient file for record keeping. *The following forms/documents shall be reviewed by our Agency's clinician upon the initial visit to new patients or prior to initiating services. -Welcome letter. -Patient Rights and Responsibilities in writing. -Advance Directive information. -Advance Beneficiary Notice (ABN) if applicable. -State Hotline numbers, office phone. -Nondiscrimination in receiving services/Limited English Proficiency (LEP) information. -Section 504 Notice of program accessibility. -Outcome and Assessment Information Set (OASIS) privacy statement. -Health Insurance Portability and Accountability Act (HIPPA) statement. -Grievance (complaint) procedure. -Infection Prevention and Control. -Agency homecare services, which include services offered, names of the Administrator, Agency owner, clinical director and Agency contact phone. -State resources, including Area Agency on Aging, Center for Independent Living, Protection and Advocacy Agency, Aging and Disability Resource Center and Quality Improvement Organization (QIO). -Emergency/Disaster plan/procedures, including information regarding preparing for disasters/emergencies, communication with us during an emergency, pet considerations, what to plan to take with you if you need to be evacuated. *At the start of services, our Agency will establish a written service agreement with the patient, which will be signed and dated by the patient and the Agency. The agreement will contain the following: -Services to be provided. -Rates/changes for services paid with private funds. -The extent to which payment for home health agency (HHA) services may be expected from Medicare, Medicaid, or any other Federally funded or Federal aid program known to the agency. -The charges the individual may have to pay before care is initiated. -Any changes in the information provided in accordance with the Centers for Medicare and Medicaid Services (CMS) regulations when they occur. 1. Patient #4 was admitted to the agency in February 2023 with a diagnosis of Multiple Sclerosis (an autoimmune disease attacking the brain and spinal cords nerve protecting myelin [insulating sheath around nerve fibers]). Reveiw of the clinical record indicated the initial start of care visit was completed on 2/14/23. Further review of the clinical record did not include any signed documents or consents that were provided and reviewed upon admission. During an interview on 1/20/26 at 10:45 A.M., the Administrative Assistant said there were no signed admission documentations and consents for Patient #4, as required.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, policy review, and interview, the agency failed to ensure infection control guidelines were maintained 1. after the use of medical equipment for patient (#2) and 2. after the use of a glucometer (a portable device used to measure the amount of glucose (sugar) in the blood) for patient (#1), during the observation of 2 of 2 patient home visits. Findings include: Review of the agency's policy entitled, Hand Washing, dated May 2025-2026, included, but not limited to, the following: -Current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines: *Use an alcohol-based hand rub for basic hand hygiene. *Clean hands before and after patient care and with each glove use. -Employees providing care/services in the home will wash their hands at least: *Before and after contact with the patient. *After touching an inanimate object on or near the patient. *Before gloves are put on and after gloves are taken off. Review of the CDC's Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, indicated the following: *Wear gloves when needed for Standard Precautions (when you anticipate that you will come in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment). *When to change gloves and clean hands: -If gloves become soiled with blood or body fluids after a task. -If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs. -If they look dirty or have blood or body fluids on them after completing a task. 2. Patient #1 was admitted to the agency in October 2020 with a diagnosis of Type 2 Diabetes Mellitus (chronic condition where the body either doesn't produce enough insulin [hormone] or doesn't use insulin effectively, leading to high blood sugar) with diabetic neuropathy (nerve damage caused by diabetes). Review of the physician ordered Home Health Certification and POC, dated 11/27/25 through 1/27/26, indicated the following: -SNV: once a week, and 3 PRN visits. -Medication Administration Visit (MAV): 13 times a week. -Insulin; Glargine-yfgn (long acting, man-made insulin): inject 12 units at bedtime. -Humalog kwipen (pre-filled, disposable pen containing rapid-acting insulin Lispro), sliding scale: twice daily. -Check blood sugar at least once daily with each skilled nurse visit. During a home visit with Nurse #1 on 1/16/26 at 3:00 P.M., the following was observed: Nurse #1 donned (put on) clean gloves after using an alcohol-based hand gel, before preparing a glucose monitor to do a finger stick blood test on the patient. The nurse cleansed the patient's finger with an alcohol pad and then obtained the blood sample. The nurse then recorded the results in her tablet and proceeded to clean the glucose monitor before putting it away. She then removed the Glargine-fygn insulin vial and the Humalog kwipen from the patient's refrigerator. She also opened a draw to retrieve the instructions for the sliding scale insulin dose and removed a syringe from a box on a countertop. Nurse #1 administered the Glargine-fygn insulin as ordered and then adjusted the Humalog kwipen and administered 2 units short acting insulin. The nurse then returned the insulins to the patient's refrigerator and disposed of the needle in a sharps container under the counter. During this observation, Nurse #1 did not doff (remove) her gloves after obtaining the finger stick blood sample, cleaning equipment and putting it away, obtaining insulins and a syringe (touching objects in the environment), and then administering the insulins. She doffed her dirty gloves and performed hand hygiene at the end of the visit right before leaving. During an interview on 1/16/26 at 3:45 P.M., Nurse #1 said she always wears the same pair of gloves throughout a patient's visit. During an interview on 1/20/26 at 9:00 A.M., the Administrator said Nurse #1 should have removed her gloves, performed hand hygiene after obtaining a fingerstick blood sugar and administering insulin to minimize the risk of cross contamination. She also said staff should doff gloves, preform hand hygiene and don new gloves between tasks. Review of the agency policy entitled, Infection Control, dated 5/2025-2026, included the following: *Vital Sign Equipment and Supplies will be cleaned and disinfected with a low-(designed to eliminate most bacteria, some viruses, and some fungi) or intermediate-level (designed to kill bacteria, viruses and most fungi, but does not necessarily kill bacterial spores) disinfectant in the home after use and prior to placing the equipment back in the nursing bag for use on another patient. 1. For Patient #2, the agency staff failed to clean vital sign equipment after use during a home visit observation. Patient #2 was admitted to the agency in December 2025 with a diagnosis of depressive disorder. Review of the Home Health Certification and Plan of Care (POC) for certification period, 12/1/25 through 1/29/26, indicated the following: *Skilled Nurse Visit (SNV) frequency: 1 visit every week for 9 weeks and 3 as needed (PRN) visits. During a home visit on 1/20/26 at 11:00 A.M. with the Clinical Manager, the surveyor observed the following: The Clinical Manager assessed Patient #2 blood pressure with a sphygmomanometer (blood pressure cuff) and stethoscope. He assessed the patient's oxygen saturation level and pulse by placing a pulse oximeter (a small device clipped onto a finger that measures the blood oxygen level and pulse by shining a light through a fingertip). He assessed the patient's temperature by placing a digital thermometer in close proximity to the patient's forehead. After completing the assessment of the patient's blood pressure, temperature, pulse and oxygen saturation level, the Clinical Manager did not disinfect his equipment and placed the pulse oximeter, stethoscope, blood pressure cuff and thermometer back into his bag. During an interview on 1/20/26 at 11:20 A.M., the Clinical Manager said he did not disinfect his equipment prior to placing them back into his bag, as required.

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, policy review and interview, the agency failed to ensure that services were provided as ordered by the physician or allowed practitioner, as indicated in the plan of care, for 2 patients (#5 and #7), out of a total sample of 7 patients. Findings include: Review of the agency policy entitled, Plan of Care (POC), dated 5/2025-2026, included the following: *Each patient will receive 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 physician. 1. For Patient #5, the agency failed to ensure a.) 1 Skilled Nurse Visit (SNV) was provided as per POC and b.) wound treatments orders were provided, as ordered. Patient #5 was admitted to the agency in November 2025 with a diagnosis of Type 1 Diabetes Mellitus (a chronic condition where the pancreas makes little or no insulin) without complications and chronic venous hypertension (high, persistent pressure in leg veins) with ulcer (open sore) of left lower extremity. a.) Review of a physician order, dated 1/5/26, indicated for 2 Skilled Nurse Visits (SNVs) weekly for 9 weeks and 3 visits as needed (PRN) until episode ends 1/19/26. Review of the clinical record indicated only 1 SNV was provided the week of 1/11/26., not 2 as ordered. b.) Review of a POC clarification order, dated 11/22/25, indicated the following: Foot: dorsal foot (top of the foot), left lower leg lateral (area between the knee and foot on the outer side of the leg), and left lower leg medial (inner part of the lower leg) twice weekly, wash with normal saline, pat and dry: cover with Puracol Plus Microscaffold collagen (gel wound dressing that supports the development of cells for healing), 4 inch by 4 inch, then non-woven non-sterile gauze sponge, wrap with Unna boot (a medicated, paste-impregnated compression bandage) and secure with Coban (brand name) self adherent wrap. Review of the documentation for the SNVs that occurred on 11/24/25, 11/26/25, 12/1/25, 12/3/25, 1/5/26, 1/9/26, and 1/12/26 indicated the wound treatments were not provided, as ordered. During an interview on 1/20/26 at 1:00 P.M., after reviewing the clinical record, the Administrator said the POC was not followed relative to the SNV scheduled for the week of 1/11/26. She further said the wound dressing treatments on the dates listed were not provided, as ordered. 2. Patient #7 was admitted to the agency in June 2025 with a diagnosis of Type 2 Diabetes Mellitus (body cannot use insulin correctly and sugar builds up in the blood). Review of the Home Health Certification and POC for certification period, 8/19/25 through 10/17/25, indicated the following: -SNV: 1 visit weekly for 9 weeks and 3 PRN visits. Review of the clinical record indicated no SNV was provided the week of 9/21/25. During an interview on 1/16/26 at 2:15 P.M., the Administrator said there was no SNV provided the week of 9/21/25 and the POC was not followed, as required.

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 record review, policy review and interview, the agency failed to ensure staff communicated with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care, for 2 patients (#6 and #5), out of total sample of 7 patients. Findings include: 2. Patient #5 was admitted to the agency in November 2025 with a diagnosis of Type1 Diabetes Mellitus (a chronic condition where the pancreas makes little or no insulin) without complications. Review of a physician order, dated 1/5/26, indicated for 2 SNVs weekly for 9 weeks and 3 visits, as needed (PRN), until episode ends 1/19/26. Review of the clinical record indicated only 1 SNV was provided the week of 1/11/26. Further review of the clinical record did not contain any documentation that the physician had been notified of the missed visit. During an interview on 1/20/26 at 1:00 P.M., the Administrator said the physician was not notified of the missed SNV visit for the week of 1/11/26, as required. Review of the agency's policy entitled, Plan of Care (POC), dated May 2025-2026, indicated the following: *POC is a written plan that specifies the care and services necessary to meet the patient-specific needs identified in the comprehensive assessment, and the measurable outcomes that the agency anticipates would occur as a result of implementing and coordinating the POC. *Promptly alert the physician who is responsible for the Agency POC to any changes in the patient's condition or needs that would suggest that measurable outcomes are not being achieved and/or that the Agency should alter the plan. Review of the agency's policy entitled, Refusal of Care/Services, dated May 2025-2026, indicated the following: *In the case of patient refusal of skilled care, our clinical staff will document the communication with the physician, as well as the measures taken to investigate the patient refusals of care and the intervention of agency staff to obtain patient participation with the POC. 1. Patient #6 was admitted the agency in September 2024 with a diagnosis of Bipolar Disorder (a mental illness causing extreme shifts in mood, energy and activity, from manic highs to depressive lows). Review of the physician ordered Home Health Certification and POC, dated 9/19/25 through 11/17/25, indicated the following: -Skilled Nurse Visit (SNV): once a week for 9 weeks. -Medication Administration Visit (MAV): 6 times a week for 9 weeks. Review of the clinical record indicated the following missed MAV notes and a SN visit note that indicated the physician was not notified of services not provided, as ordered. -Missed MAV notes dated 9/25/25, 9/26/25, 9/27/25, 9/28/25, 9/29/25, 10/15/25, 10/17/25, 11/5/25 and 11/15/25. -A missed SNV note, dated 9/30/25. Review of the physician ordered Home Health Certification and POC, dated 11/18/25 through 1/16/26, indicated the following: -SNV: once a week for 9 weeks. -MAV: 6 times a week for 9 weeks. Review of the clinical record indicated the following missed MAV notes that indicated the physician was not notified of services not provided as ordered -A missed MAV note dated 11/22/25. -A missed MAV note, dated 11/23/35. During an interview on 1/16/25 at 1:45 P.M., after reviewing Patient #6's clinical record, the Administrator said staff had not notified the physician, as required, when services that were ordered in the POC were not provided.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure all entries must be legible, clear, complete, and appropriately authenticated, dated, and timed, for 5 patients (#1, #4, #6, #2, and #5) out of a total sample of 7 patients. Findings include: 4. For Patient #2, the agency failed to ensure a.) a Home Health Certification and POC was signed timely by the physician and b.) a SNV note was completed and signed by the nurse. Patient #2 was admitted to the agency in December 2025 with a diagnosis of depressive disorder. a.) Review of the clinical record contained a Home Health Certification and POC for certification period, dated 10/2/25 through 11/30/25, that was signed by the physician on 11/14/25. b.) Review of the Home Health and Certification and POC for certification period, dated 12/1/25 through 1/29/26, indicated the following: *SNV frequency: 1 visit every week for 9 weeks and 3 PRN visits. Review of the clinical record on 1/20/26 indicated an incomplete and unsigned SNV note, dated 1/16/26. During an interview on 1/20/26 at 12:45 P.M., the Administrator said the physician signed the Home Health Certification and POC for certification period 10/2/25 through 11/30/25 on 11/14/25, beyond the 30 day timeframe required by the agency. She further said the nurse is required to complete the visit note within 48 hours and the 1/16/26 SNV note was not completed and signed, as required. 5. For Patient #5, the agency failed to ensure a.) a Home Health Certification and POC was timely signed by the physician, and b.) 2 SNV notes were completed and signed by the nurse. Patient #5 was admitted to the agency in November 2025 with a diagnosis of Type1 Diabetes Mellitus (a chronic condition where the pancreas makes little or no insulin) without complications and chronic venous hypertension (high, persistent pressure in the legs) with ulcer (open sore) to the left lower extremity. a.) Review of the clinical record contained a Home Health Certification and POC for certification period, dated 11/22/25 through 1/20/26, that was signed by the physician on 1/12/26. b.) Review of the Home Health and Certification Plan of Care POC for certification period, dated 12/1/25 through 1/29/26, indicated the following: *SNV:1 visit weekly for 9 weeks and 3 PRN visits. Review of the clinical record on 1/16/26 indicated 2 incomplete and unsigned SNV notes, dated 1/9/26 and 1/12/26. During an interview on 1/20/26 at 1:00 P.M., the Administrator said the physician signed the Home Health Certification and POC for certification period 11/22/25 through 1/29/26 was signed late on 1/12/26, beyond the 30 day timeframe required by the agency. She further said said the 1/9/26 and 1/12/26 SNV notes were not signed and completed within the required 48 hour of a visit. Review of the agency's policy entitled, Plan of Care (POC), dated May 2025-2026, indicated the following: *Individualized written POC would specify the care and services necessary to meet the patient's needs, including the patient and caregiver education and training that the agency will provide, specific to the patient's care needs. *Frequency and duration of the therapeutic interventions will be included. Review of the agency's policy entitled, Orders: Signed in 30 Days, dated May 2025-2026, indicated the following: *All POC, verbal orders and changes in orders will be signed by the certifying physician within 30 days and filed in the patient's clinical file. Review of the agency's policy entitled, Admission Documentation/Patient Education, dated May 2025-2026, indicated the following: *Upon admission to the agency, certain documentation will be provided to, explained and reviewed with, and signed by the patient and by the admitting clinician. 1. For Patient #1, the facility failed to ensure a.) the POC included the duration for the visits during the physician ordered certification period, and b.) visit documentation was complete. Patient #1 was admitted to the agency in October 2020 with a diagnosis of Type 2 Diabetes Mellitus (chronic condition where the body either doesn't produce enough insulin [hormone] or doesn't use insulin effectively, leading to high blood sugar) with diabetic neuropathy (nerve damage caused by diabetes). Review of the physician ordered Home Health Certification and POC, dated 11/27/25 through 1/27/25, indicated the following: -Skilled Nurse Visit (SNV): once a week, and 3 as needed visits (PRN). -Medication Administration Visit (MAV): 13 times a week. a.) Further review of the POC order did not include a duration for the SNVs nor the MAVs. b.) Review of the clinical record included MAV A.M. and P.M. notes, dated 1/17/26, that were incomplete. During an interview on 1/20/26 at 9:39 A.M., the Administrator said the order for SNVs and MAVs were incomplete, and did not include the duration, as required. She said staff are required to have their documentation completed within 48 hours and the MAV notes for 1/17/26 had not been completed within 48 hours, as required. 2. For Patient #4, the agency failed to ensure that visit documentation was complete. Patient #4 was admitted to the agency in February 2023 with a diagnosis of Multiple Sclerosis (an autoimmune disease attacking the brain and spinal cords nerve protecting myelin [insulating sheath around nerve fibers]). Review of the physician ordered Home Health Certification and POC, dated 12/3/25 through 1/31/26, indicated the following: -SNV: once a week for 9 weeks, and 3 PRN visits. -MAV: 6 times a week for 9 weeks. Review of the clinical record indicated morning (between 10:00 A.M. and 10:30 A.M.) MAV notes dated 1/17/26 and 1/18/26 were incomplete. During an interview on 1/20/26 at 11:30 A.M., the Administrator said the MAV documentation had not been completed within the 48 hours, as required. 3. For Patient #6 the agency failed to ensure a.) a physician order was signed within 30 days, and b.) admission consents were signed on the day of admission/start of care. Patient #6 was admitted the agency in September 2024 with a diagnosis of bipolar disorder (a mental illness causing extreme shifts in mood, energy and activity, from manic highs to depressive lows). a.) Review of the physician ordered Home Health Certification and POC, dated 9/19/25 through 11/17/25, indicated it was not signed by the physician until 10/27/25, not within 30 days as required. During an interview on 1/16/25 at 1:50 P.M., the Administrator said the physician order was signed late, and not within the required 30 days. b.) Review of the clinical record indicated the initial admission visit by staff was completed on 9/24/24. Further review of the clinical record indicated the admission documentation and consents were all signed and dated on 9/23/24 by the patient and the clinician. During an interview on 1/20/26 at 10:40 A.M., the Administrator said the documents were inaccurate because of the wrong date. She said should have dated it correctly for 9/24/24, which was the start of care.

A Recertification survey was conducted at ICK-Assurance Home Health Care on 01/11/203, 01/12/2023, and 01/13/2023 for compliance with 42 CFR Part 484.102 Emergency Preparedness for Home Health Agencies. As a result of this survey, it was determined the agency was in compliance with these requirements. No deficiencies were cited.

A Recertification survey was conducted at ICK-Assurance Home Health Care on 01/11/2023, 01/12/2023, and 01/13/2023 to determine compliance with the 42 CFR Part 488 requirements for Home Health Agencies. As a result of this survey, it was determined the agency was not in compliance with these requirements. Deficiencies were cited.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that its Nursing staff completed the initial comprehensive assessment visit within 48 hours of the referral, for one Patient (#4), out of a total sample of seven Patients. Findings include: Patient #4 was admitted to the Agency in July 2022 with a diagnosis of Bipolar Disorder (a form of mood disorder defined by manic or hypomanic episodes). Review of the clinical record indicated a referral, dated 7/6/22, was made for Patient #4 to receive home care services from the Agency. Review of the clinical record indicated an initial comprehensive assessment, dated 7/11/22, was completed by a Registered Nurse (RN). During an interview on 1/13/23 at 12:20 P.M., the Chief Executive Officer (CEO) said the Patient's Case Worker was not able to meet the RN and Patient #4, to do the initial comprehensive assessment within 48 hours of the referral, as required, so the assessment was late.

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 record review and interview, the Agency failed to ensure its staff obtained an accurate Physician's order for one Patient (#5), out of a total sample of seven Patients. Findings include: Review of the Agency policy titled, Medication Management, dated 12/2018, included but was not limited to: Medication Reviews & Reconciliation: Goals: -To identify significant medication issues and notify physician to resolve them, -To identify knowledge deficits and obtain orders to teach the patient to manage their medications, -To prevent unnecessary Emergency Room (ER) visits or re-hospitalizations related to medication management. Patient #5 was admitted to the Agency in December 2020 with a diagnosis of neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems). Review of the Physician's order for certification period 12/11/22 through 2/8/23 indicated the following: -Acetaminophen (used to treat fever and mild to moderate pain) Oral 500 milligram (mg) 2 capsules (caps) Take 2 tablet Take 1 tablet every 6 hours as need for pain. By mouth. Further review of the medication order did not specify if one or two tablets were needed to be administered. During an interview on 1/13/23 at 9:30 A.M., after reviewing the clinical record, the Chief Executive Officer (CEO) said the Acetaminophen order was incomplete and misleading and was not clear in dosage administration, as required.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the staff notified the Physician when there was a change in the ordered Skilled Nurse Visit (SNV) frequency for one Patient (#1), out of a total sample of seven Patients. Findings include: Patient #1 was admitted to the Agency in August 2021 with a diagnosis of Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar), Review of the Physician order for the certification period 8/28/22 through 10/26/22 indicated: -SNV: Two visits per day for 60 days. Further review of the SNVs for the certification period indicated the SNV occurred once daily from 9/12/22 through 9/16/22. Review of the medical record did not contain a Physician order for the change in SNV frequency for 9/12/22 through 9/16/22. During an interview on 1/13/22 at 1:31 P.M., after reviewing the clinical record, the Chief Executive Officer (CEO) said Patient #1 received her/his medications at a daycare program that she/he attended 9/12/22 through 9/16/22 and thereby required a daily SNV. He further said there was no Physician order indicating the decrease in SNV for 9/12/22 through 9/16/22, as required.

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 interview, the Agency failed to ensure its staff provided services that were ordered by the Physician and as indicated in the plan of care for one Patient (#5), out of a total sample of seven Patients. Findings include: Patient #5 was admitted to the Agency in December 2020 with a diagnosis of neuromuscular dysfunction of the bladder (lack of bladder control due to brain, spinal cord or nerve problems). Review of the Physician order for certification period 8/13/22 through 10/11/22 indicated: -Four Skilled Nurse Visits weekly for nine weeks. Review of the clinical record indicated five SNVs occurred weekly during the certification period. Further review of the clinical record did not contain a Physician order for the increase to five SNVs weekly. During an interview on 1/13/23 at 2:30 P.M, after reviewing the clinical record, the Chief Executive Officer (CEO) said there was no Physician order in place for the weekly five SNVs for the certification period 8/13/22 through 10/11/22, as required.