Every finding on record at Jola Home Health Service, Inc

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA), failed to ensure all staff participated in the annual testing for emergency and disaster preparedness drill. This deficient practice had the potential to result in harm and injury, due to the staff’s lack of knowledge to respond effectively during an emergency/disaster situation. During record review at the HHA’s office on 2/9/2023, it was noted two of the HHA staff (Staff 1 and LVN 2) did not attend the annual emergency preparedness drill, which was held on 2/15/2022. During an interview with the Director of Patient Care Services (DPCS) on 2/9/2023 at 2:40 p.m., DPCS stated one of the staff (Staff 1) who did not participate in the 2022 annual emergency preparedness drill had resigned on 2/4/2022, which was prior to the drill. The HHA was not able to provide a resignation letter for Staff 1. DPCS stated LVN 2 was still an active employee at the HHA. DPCS further stated that emergency preparedness drills were important. He stated, “The goal is to prepare staff, so they know their roles and know what to do in an emergency situation.” A review of the HHA’s policy, titled “Emergency Management Plan,” indicated that the agency will test the emergency management plan at least annually, either in response to an actual emergency or in a planned exercise. All actual responses and exercises will be documented and critiqued through a multidisciplinary process that includes administrative, clinical, and support staff.”

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 323 N. Prairie Avenue, Suite 425, Inglewood, CA 90301. Representing the California Department of Public Health: Health Facilities Evaluator Nurse, Surveyor ID: 45783 Health Facilities Evaluator Nurse, Surveyor ID: 44911 Unduplicated admissions: 85 Current census: 19 Sample size: 7 Home visits: 3 Record reviews: 7

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure the gastrostomy tube (G-tube, a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) was included on the comprehensive assessment for one of seven (Patient 6) sampled patients. This deficient practice had the potential to lead to the patient not receiving the proper care regarding the care for the g-tube. A review of Patient 6’s profile indicated a Start of Care (SOC) date of 11/2/2022, with a primary diagnosis of Alzheimer’s disease (a brain disorder that destroys memory and other important mental functions) and secondary diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain), essential primary hypertension (HTN, high blood pressure), viral pneumonia (viral infection that inflames air sacs in one or both lungs, which may fill with fluid), and presence of other specified devices. A review of Patient 6’s Recertification Outcome and Assessment Information Set (OASIS, an instrument/data collection tool used to collect and report assessment data by home health agencies) dated 12/28/2022 indicated Patient 6 had dysphagia (trouble swallowing) and a tube feeding was present using g-tube. A review of Patient 6’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period from 1/2/2023 to 3/2/2023 indicated the Skilled Nurse (SN) was scheduled to visit twice a week for three weeks and then once a week for six weeks for the assessment of the patient’s cardiovascular (relating to the heart and blood vessels) status, medication management, activities permitted, assess neurological (relating to disorders of the nervous system) status, and to assess the patient with Alzheimer’s disease. During a concurrent interview and record review on 2/9/2023 at 11:18 a.m. with the Director of Patient Care Services (DPCS) of Patient 6’s POC for the certification period from 1/2/2023 to 3/2/2023, the DPCS verified that the POC did not indicate the SN was to observe and assess Patient 6’s G-tube. The DPCS stated the POC should indicate the SN was to assess and observe Patient 6's G-tube. A review of the HHA’s policy and procedure (P&P) titled, “Patient Assessment/Reassessment Policy”, dated 1/1/2020 indicated the purpose of the patient assessment and reassessment is to ensure all patients needs are assessed and evaluated on an on-going basis by a qualified staff member. The P&P indicated each patient must receive a patient-specific comprehensive assessment that accurately reflects the patient’s current health status and the comprehensive assessment must incorporate the use of the current version of the OASIS. The P&P indicated the data collected during the assessment process is utilized to develop the POC.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) staff failed to review all the medications and update the medication profile with currently used medications for four of seven sampled patients (Patient 1, 4, 5, and 6). a. For Patient 1, the medication profile listed the wrong doses for three medications (Ferrous Sulfate, B-12, and Eliquis). The dose that Patient 1 takes is the same as the dose printed on the medication label. b. For Patient 4, the Medication Profile indicated Combigan (eye medication) to be administered by mouth instead of dropped in the eye and the order did not indicate if the medication was to be instilled in one eye (right or left) or both eyes. c. For Patient 5, multiple medications were listed on the current Medication Profile but patient is not taking these medications, some medication were ordered as extended release but not what the patient is taking, and incorrect dosage frequencies. d. For Patient 6, Fibersource (tube feeding formula) was listed on the patient’s current Medication Profile as discontinued and current medications are listed to be administered by mouth instead of through gastrostomy tube (g-tube, a tube inserted into the stomach through a surgical incision use for feeding and administration of medication for a resident unable to swallow) which is the incorrect route of administration. This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: b. A review of Patient 4’s profile indicated a Start of Care (SOC) date of 9/9/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure) and secondary diagnoses of unspecified glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging the nerve in the back of the eye called the optic nerve), and unspecified cataract (a cloudy area in the lens of the eye). A review of Patient 4’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period from 1/7/2023 to 3/7/2023 indicated Skilled Nurse (SN) to visit once a week for nine weeks to assess and instruct patient on medication management. A review of Patient 4’s Medication Profile printed on 2/7/2023 indicated the medication Combigan 0.2% - 0.5% ophthalmic (relating to the eye) solution one drop twice daily by mouth. On 2/8/2023 at 12:05 PM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 4’s home residence. Patient 4 was sitting on the couch in the living room. During a concurrent interview and record review on 2/8/2023 at 12:12 PM with LVN 1 and Patient 4’s Medication Profile, LVN 1 verified the Medication Profile indicated the incorrect route to take Combigan ophthalmic solution of by mouth or if the medication should be given to one eye or both eyes. During an interview on 2/8/2023 at 12:32 PM with LVN 1, LVN 1 stated she reviews the patient’s medications during every SN visit. LVN 1 stated she did not realize the Medication Profile indicated the incorrect route of administration or that the profile did not indicate which eye to give the medication. LVN 1 stated the Medication Profile should be updated to ensure the patient takes the medication correctly. c. A review of Patient 5’s profile indicated a Start of Care (SOC) date of 12/3/2022 with a primary diagnosis of Diabetes Mellitus (DM, a disease in which blood sugar levels are too high) and secondary diagnosis of hypertrophic cardiomyopathy (a condition affecting the left ventricle which is the main pumping chamber of the heart), essential primary HTN, disorder of bone density and structure, primary osteoarthritis (a degeneration of joint cartilage and the underlying bone which causes pain and stiffness especially in the hip, knee, and thumb joints), insomnia (condition where a person may have trouble falling asleep, staying asleep or getting good quality sleep), cataract, low back pain, and constipation (having fewer than three bowel movements a week). A review of Patient 5’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period from 2/1/2023 to 4/1/2023 indicated Skilled Nurse (SN) to visit once a week for nine weeks to provide skilled assessment, teaching/training and reinforcement of teaching to properly assess medication management. A review of Patient 5’s Medication Profile printed on 2/7/2023 indicated the patient is taking the following medications: - Fexofenadine Hydrochloride (HCL) 180 milligrams (mg, unit of weight) tablet, one tablet daily as needed for allergy, by mouth - Mucinex DM 600/30mg tablet, one tablet twice a day by mouth (medication used to relieve chest congestion and calming a cough) - Tramadol 100mg tablet, one tablet every eight hours as needed for pain, by mouth - Pantoprazole 40mg oral delayed release tablet, one tablet once daily, by mouth (medication used to treat damage from gastroesophageal reflux disease, GERD, a condition where backward flow of acid from the stomach causes heartburn and possible injury to the esophagus, tube between the throat and stomach) - Oxybutynin extended release 10mg tablet, one tablet once daily, by mouth (medication used to treat symptoms of an overactive bladder) - Vitamin C 500mg capsule, one capsule once daily, by mouth (vitamin supplement) On 2/9/2023 at 10:08 AM, a home visit was conducted with LVN 1 at Patient 5’s home residence. Patient 5 was sitting on the couch in the living room with patient’s sons/patient caregivers (PCG) in the home. During a concurrent interview and record review on 2/9/2023 at 10:17 AM with Patient 5 and LVN 1 of Patient 5’s medications and Medication Profile, the following discrepancies were identified: - Fexofenadine HCL, this medication was not present in the patient’s home, Patient 5 stated she does not take this medication anymore. LVN 1 stated this medication was discontinued, LVN 1 stated the Medication Profile should indicate the medication was discontinued. - Mucinex DM, this medication was not present in the patient’s home, Patient 5 stated she does not take this medication anymore. LVN 1 stated this medication was discontinued, LVN 1 stated the Medication Profile should indicate the medication was discontinued. - Tramadol 100mg, this medication was not present in the patient’s home, Patient 5 stated she does not take this medication anymore. LVN 1 stated this medication was discontinued, LVN 1 stated the Medication Profile should indicate the medication was discontinued. - Pantoprazole 40mg, medication bottle does not indicate the tablets are delayed release tablets, LVN 1 stated she was not aware the medication bottle did not indicate delayed release tablets - Oxybutynin extended release 10mg, order is for one tablet daily, medication bottle indicated to take the medication twice a day, Patient 5 stated she takes this medication once a day. LVN 1 stated she was not aware the medication bottle indicated to take this medication twice a day. - Vitamin C 500mg capsule, order is for one tablet daily, medication bottle indicated to take the medication twice a day, Patient 5 stated she takes this medication twice a day. LVN 1 stated she was not aware the medication bottle indicated to take this medication twice a day - Nitrofurant Mono Macr 100mg capsule, this medication is not listed on the Medication Profile, the medication bottle indicated to take one capsule twice a day. LVN 1 stated she was not aware the patient was taking this medication. During an interview on 2/9/2023 at 10:39 AM with LVN 1, LVN 1 stated she was not aware of the mistakes on the Medication Profile with what the patient has in the home. LVN 1 stated she reviews the medications with the patient every SN visit but does not know why the Medication Profile is not updated. LVN 1 stated the importance to update and review the medications with the Medication Profile to identify any possible interactions, any potential side effects, and to ensure the patient is taking the proper therapy. LVN 1 stated she does not have a Medication Profile with her, she says she looks at the Medication Profile in the patient’s admission folder. LVN 1 stated she should have a copy of the current Medication Profile in order to accurately review the patient’s medications. d. A review of Patient 6’s profile indicated a Start of Care (SOC) date of 11/2/2022 with a primary diagnosis of Alzheimer’s disease (a brain disorder that destroys memory and other important mental functions) and secondary diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain), essential primary hypertension (HTN, high blood pressure), viral pneumonia (viral infection that inflames air sacs in one or both lungs, which may fill with fluid), and presence of other specified devices. A review of Patient 6’s Recertification Outcome and Assessment Information Set (OASIS, an instrument/data collection tool used to collect and report assessment data by home health agencies) dated 12/28/2022 indicated Patient 6 had dysphagia (trouble swallowing) and tube feeding was present using g-tube. A review of Patient 6’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period from 1/2/2023 to 3/2/2023 indicated Skilled Nurse (SN) to visit twice a week for three weeks and then once a week for six weeks for the assessment of the patient’s cardiovascular (relating to the heart and blood vessels) status, medication management, activities permitted, assess neurological (relating to disorders of the nervous system) status, and to assess the patient with Alzheimer’s disease. A review of Patient 6’s Medication Profile printed on 2/7/2023 indicated Fibersource HN/B4150 55milliliters (ml, unit of volume) per hour (ml/hr), by nasogastric tube (NGT, tube that is inserted through the nose, down the throat and esophagus, and into the stomach used to give medications, liquids, and liquid food or used to remove substances from the stomach), for nutrition which the profile indicated the order was started on 8/30/2021 and was discontinued 9/2/2021. The Medication Profile indicated all active medications were to be administered by mouth. A review of Patient 6’s Skilled Nurse Visit Notes dated 1/18/2023, 1/23/2023, 1/25/2023, 1/30/2023, and 2/2/2023 all indicate under Nutrition section that Patient 6 is receiving Fibersource nutrition through g-tube. During an interview on 2/9/2023 at 11:18 AM with Director of Patient Care Services (DPCS), DPCS stated SN is to review all medications on Medication profile with what the patient has in the home during every SN home visit. DPCS verified Patient 4’s Medication Profile indicates the incorrect route of administration for the patient’s eye drops and it should include the site to administer the medication to ensure the therapy is given correctly and to the correct site. DPCS stated that LVN 1 should have an updated Medication Profile for Patient 5 when conducting the home visit to review what medications the patient has in the home and to identify any discrepancies in the medications the patient is taking. DPCS stated he was not aware the nutrition feeding of Fibersource for Patient 6 should be listed on the Medication Profile. DPCS stated all Patient 6’s medications are administered through the patient’s g-tube, not by mouth as indicated on the Medication Profile. DPCS stated the Medication Profile should indicate the correct route to administer medications. DPCS stated all medication reviews should include comparing and updating the Medication Profile with what the patient is currently taking in the home including the correct site to administer the medication and the correct route to administer the medication all to ensure the patient’s are receiving the proper medication therapy and to identify any medication interactions and side effects. A review of the HHA’s policy and procedure (P&P) titled Medication Management, undated, indicated the agency has a medication management system that supports client safety and improve quality of care treatment and services by reducing practice variation, errors and misuse of medications. The P&P indicated the purpose of the policy is to reduce errors and improve quality of care and promote safety throughout the home care program. The P&P indicated a comprehensive client assessment performed at start of care and other defined points in time include review of all medications the client is taking (prescribed, samples, over the counter, herbal remedies, as needed medications) and records this in the client record. The P&P indicated the medications in the home are reviewed with the client/family to determine current medications and client understanding of the medications actions and side effects. The P&P indicated medications in the home not on the current plan of care will be checked to assure they have not expired, and to review if medications are being prescribed by multiple doctors. A review of the HHA’s P&P titled, “Plan of Care Policy”, dated 1/1/2020, indicated the Plan of Care indicated when staff is observing and assessing the effectiveness of medications, a description of the medications, including the name, dosage, frequency, route of each medication, and an indication if medication is new or changed. A review of Patient 1’s clinical record indicated a Start of Care date (SOC) of 12/21/2022 with a primary diagnosis of Alzheimer’s disease (a type of brain disorder that causes problem with memory, thinking, and behavior; it is a gradually progressive condition). A review of Patient 1's “Home Health Certification and Plan of Care” for the certification period of 12/21/2022 to 2/18/2023, indicated the physician ordered the Skilled Nurse (SN) to visit Patient 1 twice a week for one week, and then once a week for eight weeks. The SN was to instruct Patient 1 on disease process including who to contact if signs and symptoms persist or worsen, as well as dietary measures, medication management, activity, injury prevention, and access to community resources/support groups where indicated. The SN was also to perform a medication review each skilled nursing visit and reconcile medications as indicated. During a joint home visit with the Director of Patient Care Services (DPCS) on 2/8/2023 at 2 p.m., Patient 1 was observed lying in bed, alert and awake. Upon medication review with DPCS, it was noted Patient 1’s medication list included the following medications: - Ferrous Sulfate 525 mg. (65 Mg. elemental Iron) oral delayed release tablet one tab daily by mouth (PO). - B-12 1000 mcg. one tab daily PO. - Eliquis 5 mg. oral tablet one tab twice daily by mouth (PO). This indicated Patient 1 was taking these three medications in the specified doses. The labels on the three medications indicated the following: - Ferrous Sulfate 325 mg. (65 mg. elemental Iron) oral delayed release tablet one tab daily by mouth (PO). - Vitamin B-12 500 mcg. one tab daily PO. - Eliquis 2.5 mg. oral tablet one tab twice daily by mouth (PO). During an interview with Family Member 1 (FM 1), who acted as the primary caregiver for Patient 1, FM 1 stated Patient 1 was taking ferrous Sulfate, Vitamin B-12, and Eliquis in the doses printed on the medication labels. FM 1 stated Patient 1 has been on the same doses for ferrous sulfate, Vitamin B-12, and Eliquis “for a while.” During an interview with the DPCS on 2/8/2023 at 11:23 a.m., DPCS stated ferrous sulfate 525 MG was “a typo.” The DPCS stated, “ferrous sulfate doesn’t come in 525 MG. It’s a mistake; a typo.” The DPCS was not sure why the doses for B-12 and Eliquis were not updated in the medication profile since he stated he was not the regular nurse for Patient 1. The DPCS stated it was very important for patients to have a current and updated medication profile to avoid medication errors. A review of the HHA’s undated policy, titled “Medication Management,’ indicated “Medications in the home are reviewed with the client/family to determine current medications and client understanding of the medications actions and side effects.” A review of the HHA’s policy, titled “Plan of Care Policy,” effective 1/1/2020, indicated medications/treatments/procedures including who is to administer the medication and/or who is to perform the treatment or procedure, …a description of the medications, including the name, dosage, frequency, route of each medication, and an indication if medication is new or changed and a description of equipment and supplies, if any, necessary in the provision of treatment.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to follow the plan of care (POC) for two of seven (Patient 4 and 6) sampled patients. a. For Patient 4, the HHA failed to provide Patient 4 with a cane and walker as indicated on the POC. b. For Patient 6, the HHA failed to provide oxygen therapy as indicated on the POC. These deficient practices had the potential to result in harm and injury and to the patients not receiving the appropriate care as indicated on the POC. Findings: a. A review of Patient 4’s profile indicated a Start of Care (SOC) date of 9/9/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure) and secondary diagnoses of unspecified glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging the nerves in the back of the eye called the optic nerve), and unspecified cataract (a cloudy area in the lens of the eye). A review of Patient 4’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period from 1/7/2023 to 3/7/2023 indicated Skilled Nurse (SN) to visit once a week for nine weeks. The POC indicated the medical equipment for Patient 4 included the use of a cane and a walker. On 2/8/2023 at 12:05 PM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 4’s home residence. Patient 4 was sitting on the couch in the living room. During a concurrent observation and interview on 2/8/2023 at 12:05 PM with Patient 4 in Patient 4’s home, there was no walker or cane observed in the patient’s residence. Patient 4 stated she does not have a walker or cane and has not had either since starting HHA services. During an interview on 2/8/2023 at 12:32 PM with LVN 1, LVN 1 stated Patient 4 is able to walk on her own, the patient is independent and she does not want to use a cane or a walker. b. A review of Patient 6’s profile indicated a Start of Care (SOC) date of 11/2/2022 with a primary diagnosis of Alzheimer’s disease (a brain disorder that destroys memory and other important mental functions) and secondary diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain), essential primary hypertension (HTN, high blood pressure), viral pneumonia (viral infection that inflames air sacs in one or both lungs, which may fill with fluid), and presence of other specified devices. A review of Patient 6’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period from 1/2/2023 to 3/2/2023 indicated the Skilled Nurse (SN) was to visit twice a week for three weeks and then once a week for six weeks to instruct patient/patient caregiver (PCG) regarding the self-management of oxygen therapy, perform risk assessment and administer oxygen at two liters per minute (LPM) by nasal cannula (NC, a medical device with two prongs that sits below the nose to provide supplemental oxygen therapy to people who have lower oxygen levels). A review of Patient 6’s Skilled Nurse Visit notes dated 1/18/2023, 1/23/2023, 1/25/2023, 1/30/2023, and 2/2/2023 all indicate the oxygen saturation (how efficiently blood is carrying oxygen to the extremities furthest from the heart, including arms and legs) method is on room air (when a patient is not receiving any additional oxygen). During a concurrent interview and record review on 2/9/2023 at 11:18 AM with DPCS of Patient 4’s POC for certification period from 1/7/2023 to 3/7/2023, DPCS verified the POC indicated Patient 4's listed medical equipment included a cane and a walker. DPCS stated this was ordered for the patient to prevent falls. DPCS stated during the SN home visits, the POC should be implemented and to make sure the medical equipment is provided to the patient. DPCS stated the POC was not implemented because the medical equipment was not provided for Patient 4. DPCS stated Patient 4 did not want to use the cane or walker but was unable to provide documentation of the patient's refusal of the cane. During a concurrent interview and record review on 2/9/2023 at 11:18 AM with DPCS of Patient 6’s POC for certification period from 1/2/2023 to 3/2/2023 and Patient 6’s SN home visit notes dated 1/18/2023, 1/23/2023, 1/25/2023, 1/30/2023, and 2/2/2023, DPCS verified the POC indicated the SN was to administer oxygen at two liters per minute via a nasal canula. The SN visit notes all indicate the POC was not followed because the SN notes indicate the patient was on room air, not on oxygen therapy. The DPCS stated the order was changed to, as needed oxygen therapy, but agrees the POC does not reflect those changes. The DPCS was unable to provide evidence the oxygen therapy order for Patient 6 was changed. A review of the HHA’s policy and procedure (P&P) titled, “Plan of Care Policy”, dated 1/1/2020, indicated the policy of the HHA is to implement an individualized plan of care established by the patient’s doctor for each patient. The P&P indicated the purpose of this P&P is to establish a process and procedure for the development, review, and revision of the plan of care for each patient. The P&P indicated the POC will include the types of services and equipment required and orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration. The P&P indicated, if after the evaluation visit, if it is determined that the initial plan of care does not meet the patient’s needs, the attending doctor will be consulted to approve additions or modifications to the original plan.

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 record review, the home health agency (HHA) staff failed to ensure the individualized plan of care included patient and caregiver specific education and training for one of 7 sampled patients (Patient 1). This deficient practice had the potential to impede the patient’s/caregiver’s competence with self-management of disease process. A review of Patient 1’s clinical record indicated a start of care date (SOC) of 12/21/2022 with a primary diagnosis of other Alzheimer’s disease (a type of brain disorder that causes problem with memory, thinking, and behavior; it is a gradually progressive condition). A review of Patient 1's “Home Health Certification and Plan of Care” for the certification period of 12/21/2022 to 2/18/2023, indicated the physician ordered the skilled nurse (SN) to visit twice a week for one week, and then once a week for eight weeks. The SN was to instruct patient on disease process including who to contact if signs and symptoms persist or worsen as well as dietary measures, medication management, activity, injury prevention, and access to community resources/support groups where indicated. During a joint home visit with the Director of Patient Care Services (DPCS) on 2/8/2023 at 2 p.m., Patient 1 was observed lying in a bed, alert and awake. During medication review, Family Member 1 (FM 1), who acted as the primary caregiver for Patient 1, stated she always checked Patient 1’s blood glucose prior to administering Lantus. It was noted that Patient 1 used Bayer Contour Next EZ glucometer (a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip, where a chemical reaction with glucose alters the electrical conductivity of the strip) at home. When asked if FM 1 remembered the last time she calibrated the glucometer, FM 1 replied, “What is calibration?” It was explained to FM 1 that glucometer calibration was a quality control tests to assure that the glucometer was working properly. Asked FM 1 if she ever did such a test, typically using the control solution that came with the glucometer. FM 1 stated, “No.” During an interview with the DPCS on 2/8/2023 at 2:50 p.m., DPCS stated it was important to calibrate the glucometer to ensure an accurate reading. The DPCS stated, “I’m sure the nurse taught them about calibrating, but they probably forgot.” When asked what the nurse should have done to make sure the patient and/or caregiver understood the teaching, DPCS stated, “Reinforce the teaching.” During review of Patient 1’s “Skilled Nurse Visit” notes, dated 12/27/2022, 1/4/2023, 1/18/2023, and 1/24/2023, there was no documented evidence the HHA nurse educated and/or trained Patient 1 or the caregiver regarding glucometer calibration. A review of Patient 1’s “Oasis D-1” or the comprehensive assessment upon SOC did not indicate the patient and/or caregiver was educated and trained regarding glucometer calibration. A review of “Bayer Contour Next EZ User Guide” indicated a control test should be performed as follows: - When using the meter for the first time. - When a new bottle or package of test strips is opened. - If the patient thinks the meter is not working properly. - If the patient has unexpected blood glucose results. A review of the HHA’s policy, titled “Plan of Care Policy,’ effective 1/1/2020, indicated, “The Plan of Care will include k. Instructions to patient/family.”

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to inform the patient’s doctor of a productive cough for one of seven (Patient 6) sampled patients. This failure had the potential to place the patient at risk for a decline in their medical condition. A review of Patient 6’s profile indicated a Start of Care (SOC) date of 11/2/2022 with a primary diagnosis of Alzheimer’s disease (a brain disorder that destroys memory and other important mental functions) and secondary diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain), essential primary hypertension (HTN, high blood pressure), viral pneumonia (viral infection that inflames air sacs in one or both lungs, which may fill with fluid), and the presence of other specified devices. A review of Patient 6’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for certification period from 1/2/2023 to 3/2/2023 indicated Skilled Nurse (SN) to visit twice a week for three weeks and then once a week for six weeks for the SN to assess other conditions that present themselves during this episode of care. The POC indicated the SN to recognize and intervene to minimize complications and notify the doctor immediately of any potential problems that impede completion of patient recovery and desired goals. A review of Patient 6’s Skilled Nurse Visit notes dated 1/2/2023, 1/4/2023, 1/9/2023, 1/12/2023, 1/16/2023, 1/18/2023, 1/23/2023, 1/25/2023, 1/30/2023, and 2/2/2023 all indicate Patient 6 had a productive cough and all of which do not indicate the doctor was notified of the patient’s productive cough. There was no documented evidence the SN communicated Patient 6’s presentation of a productive cough to the doctor on 1/2/2023, 1/4/2023, 1/9/2023, 1/12/2023, 1/16/2023, 1/18/2023, 1/23/2023, 1/25/2023, 1/30/2023, and 2/2/2023. During a concurrent interview and record review on 2/9/2023 at 11:18 AM with DPCS of Patient 6’s SN notes dated 1/2/2023, 1/4/2023, 1/9/2023, 1/12/2023, 1/16/2023, 1/18/2023, 1/23/2023, 1/25/2023, 1/30/2023, and 2/2/2023, the DPCS verified all SN notes indicate Patient 6 had a productive cough but do not indicate the doctor was notified of the cough. DPCS stated the SN should have reported the productive cough finding to Patient 6’s doctor and to the DPCS. DPCS was unable to provide any evidence of the communication from the SN or the HHA to the doctor regarding Patient 6’s productive cough. A review of the HHA’s policy and procedure (P&P) titled, “Communication with a Patient’s Physician Policy”, dated 1/1/2020, the P&P indicated it is the policy of the HHA to identify when the agency staff are to communicate with a patient’s doctor. The P&P indicated the purpose of the P&P is to ensure agency staff contact the patient’s doctor whenever warranted by the patient’s condition. The P&P indicated communication with a patient’s doctor is required when significant changes in the patient’s condition, and/or changes in the patient’s expected response to treatment and/or medications. The P&P indicated staff members communicating with a patient’s doctor will document the communication via one or more of the HHA’s forms which are filed in the patient’s clinical record. A review of the HHA’s undated P&P titled, “Care Coordination Process”, the P&P indicated the policy is to ensure timely care coordination with the doctor on critical findings during the scheduled visits by SN. The P&P indicated the SN/general staff and other care providers shall call-in the office of any significant identified clinical changes, findings and abnormalities during the process of care, doctors must be called in immediately before initiating calls to the Case Manager/Care Coordinator at the office. A review of the HHA’s P&P titled, “Plan of Care Policy”, dated 1/1/2020, the P&P indicated the professional person responsible for any specific treatment will notify the attending doctor of significant changes in the patient’s condition. The P&P indicated “Significant change” means those changes that suggest the need to modify or develop a plan of care. The P&P indicated changes in the patient that warrant changes in the POC include changes in physical condition.

Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide ongoing education and training for one of seven sampled patients. This deficient practice placed the patient at risk for medication errors, improper management of the disease, and improper administration of treatments. A review of Patient 1’s clinical record indicated a Start of Care date (SOC) of 12/21/2022 with a primary diagnosis of Alzheimer’s disease (a type of brain disorder that causes problem with memory, thinking, and behavior; it is a gradually progressive condition). A review of Patient 1's “Home Health Certification and Plan of Care” for the certification period of 12/21/2022 to 2/18/2023, indicated the physician ordered the skilled nurse (SN) to visit twice a week for one week, and then once a week for eight weeks. The SN was to instruct the patient on disease process including who to contact if signs and symptoms persist or worsen as well as dietary measures, medication management, activity, injury prevention, and access to community resources/support groups where indicated. During a joint home visit with the Director of Patient Care Services (DPCS) on 2/8/2023 at 2 p.m., Patient 1 was observed lying in a bed, alert and awake. During the medication review, Family Member 1 (FM 1), who acted as the primary caregiver for Patient 1, stated she always checked Patient 1’s blood glucose prior to administering Lantus. It was noted that Patient 1 used Bayer Contour Next EZ glucometer (a device for measuring the concentration of glucose in the blood, typically using a small drop of blood placed on a disposable test strip, where a chemical reaction with glucose alters the electrical conductivity of the strip) at home. When asked if FM 1 remembered the last time she calibrated the glucometer, FM 1 replied, “What is calibration?” It was explained to FM 1 that the glucometer calibration was a quality control tests to assure the glucometer was working properly. Asked FM 1 if she ever did such a test, typically using the control solution that came with the glucometer. FM 1 stated, “No.” During an interview with the DPCS on 2/8/2023 at 2:50 p.m., DPCS stated it was important to calibrate the glucometer to ensure an accurate reading. The DPCS stated, “I’m sure the nurse taught them about calibrating, but they probably forgot.” When asked what the nurse should have done to make sure the patient and/or caregiver understood the teaching, DPCS stated, “Reinforce the teaching.” During a review of Patient 1’s “Skilled Nurse Visit” notes, dated 12/27/2022, 1/4/2023, 1/18/2023, and 1/24/2023, there was no documented evidence the HHA nurse educated and/or trained Patient 1 or the caregiver regarding glucometer calibration. A review of Patient 1’s “Oasis D-1” or the comprehensive assessment upon SOC did not indicate the patient and/or caregiver was educated and trained regarding glucometer calibration. A review of “Bayer Contour Next EZ User Guide” indicated a control test should be performed as follows: - When using the meter for the first time. - When a new bottle or package of test strips is opened. - If the patient thinks the meter is not working properly. - If the patient has unexpected blood glucose results. A review of the HHA’s undated policy, titled “Client/Family Education,” indicated “All client and/or caregiver education and instruction, as well as their ability to understand and respond to instructions, will be documented in the client’s record.”

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide written information regarding the medication regimen of one of seven sampled patients. This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. a. A review of Patient 1’s clinical record indicated a Start of Care date (SOC) of 12/21/2022 with a primary diagnosis of Alzheimer’s disease (a type of brain disorder that causes problem with memory, thinking, and behavior; it is a gradually progressive condition). A review of Patient 1's “Home Health Certification and Plan of Care” for the certification period of 12/21/2022 to 2/18/2023, indicated the physician ordered the Skilled Nurse (SN) to visit twice a week for one week, and then once a week for eight weeks. The SN was to instruct the patient on disease process including who to contact if signs and symptoms persist or worsen as well as dietary measures, medication management, activity, injury prevention, and access to community resources/support groups where indicated. SN was also to perform a medication review each skilled nursing visit and reconcile medications as indicated. During a joint home visit with the Director of Patient Care Services (DPCS) on 2/8/2023 at 2 p.m., Patient 1 was observed lying in a bed, alert and awake. During a review of the patient’s home folder, it was noted the medication profile in the folder was from the certification period of 5/25/2022-7/23/2022. Patient 1’s Start of Care date per “Home Health Certification and Plan of Care” was 12/21/2022. During an interview with Family Member 1 (FM 1), who acted as the primary caregiver for Patient 1, FM 1 stated she did not remember the last time the HHA nurse provided her with a copy of the medication list. During an interview with the DPCS on 2/8/2023 at 2:10 p.m., DPCS stated Patient 1 was previously admitted to the HHA and was discharged. Patient 1 was admitted again to the HHA on 12/21/2022. The DPCS stated, “That medication profile was from the previous admission.” When asked where the current medication profile was, DPCS was not sure because he stated he was not the regular nurse for Patient 1. DPCS stated, “It should be in the folder, maybe it got thrown out.” DPCS stated it was important to provide the patient with a copy of current medication list from the current certification period. The DPCS further stated by having an old medication profile from a previous admission, the family member might still be following the old medication list and give patient medications that had been discontinued or give patient the wrong dose. A review of the HHA’s undated policy, titled “Patient’s Medication Documentation,” indicated “Medication instructions may be written in the patient’s chosen language on the medication sheet left at the patient’s home.”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to accurately document in the clinical chart for one of seven (Patient 4) sampled patients. This deficient practice had the potential to result in an inaccurate assessment of the patient which could lead to harm and poor care. A review of Patient 4’s profile indicated a Start of Care (SOC) date of 9/9/2022 with a primary diagnosis of essential primary hypertension (HTN, high blood pressure) and a secondary diagnoses of diabetes mellitus (DM, a disease in which blood sugar levels are too high). A review of Patient 4’s Plan of Care (POC, documents the process of identifying a patient’s needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for the certification period from 1/7/2023 to 3/7/2023, indicated the Skilled Nurse (SN) was to visit once a week for nine weeks to assess and instruct the patient on medication management. A review of Patient 4’s Medication Profile printed on 2/7/2023, indicated the DM medication Metformin (medication used to manage DM) 500 milligrams (mg, unit of weight) was discontinued on 1/2/2023. A review of Patient 4, SN notes dated 1/12/2023, 1/18/2023, 1/28/2023, and 2/3/2023 all indicated Patient 4 managed DM by using oral hypoglycemic medication (a group of medications used to help reduce the amount of sugar present in the blood). On 2/8/2023 at 12:05 PM, a home visit was conducted with Licensed Vocational Nurse (LVN) 1 at Patient 4’s home residence. During a concurrent interview and record review on 2/8/2023 at 12:30 PM with LVN 1 of Patient 4’s Medication Profile and SN notes dated 1/12/2023, 1/18/2023, 1/28/2023, and 2/3/2023, LVN 1 verified the SN notes were documented by LVN 1 and they indicated the patient manages her DM using oral hypoglycemic medications and the Medication Profile indicated the DM hypoglycemic medication was discontinued on 1/2/2023. LVN 1 stated this was documented incorrectly since the patient is no longer taking the DM medication. LVN 1 stated the importance of accurately documenting on the clinical notes is to indicate the patient’s correct clinical condition and assessment. During a concurrent interview and record review on 2/9/2023 at 11:18 AM with the Director of Patient Care Services (DPCS) of Patient 4’s Medication Profile and SN notes dated 1/12/2023, 1/18/2023, 1/28/2023, and 2/3/2023, DPCS verified the notes do not accurately document the patient’s current clinical condition regarding the patient’s use of DM hypoglycemic medications. DPCS stated the SN notes should not have documented the use of the DM medications use by the patient when the patient is no longer taking the medication. A review of the HHA’s undated policy and procedure (P&P) titled, “Submission of Notes”, the P&P indicated the purpose of the policy is to ensure there is an accurate record of the services provided, client response and ongoing need for care. The P&P indicated all skilled services provided by nursing will be documented in the clinical record. The P&P indicated a separate note shall be completed for each visit/shift and signed and dated by the appropriate professional and any additional information that is pertinent to the client’s care or condition may be documented on the Progress Note or Flow Sheet.