Every finding on record at Physicians Choice Nebraska, LLC

Physicians Choice Home Health Care is in compliance with CFR 484.102 Condition of Participation for Home Health Agencies.

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: G536Based on record review, policy and procedure review, and staff interview, the agency failed to ensure the patient's medication orders on the Plan of Care and the medication profile (a real-time document used by the agency that lists the patient’s medications), were accurate, for 10 of 18 patient records reviewed (Patient 1, 2, 3, 4, 7, 8, 11, 13, 14, 16). The total sample size was 18. The census was 225 (180 in the Omaha office and 45 in the Lincoln branch). Findings are: A. Review of the agency’s policy and procedure titled Medication Profile C-709, reviewed/revised 9/2024, revealed: 1.The agency will reconcile all medications taken by the client at the time of admission, before and after an inpatient facility stay, at the 60-day reassessment visits, and at the time of discharge. 2. On admission, the admitting professional will document a complete list of all the medications taken by the client per the physician orders. 3. The clinician will review the medication list and confirm those medications that are to be continued or discontinued. Discrepancy will be confirmed with the physician and changes will be noted in the record and on the Physicians Plan of Care. 4. During the 60-day reassessment, the clinician will again review all medications the client is taking, update the records and the client plan of care, and verify or obtain physician orders if medications have changed. B. Review of Patient 1’s clinical record revealed: 1.The After Visit Summary from CHI Health Wound Care-St. Elizabeth to the agency, dated 9/24/24, included medication orders: a. Acetaminophen (used to treat mild to moderate pain), Hydrocodone-acetaminophen (used to treat moderate to severe pain), Hydroxyzine (used to treat anxiety), Lactulose (used to treat constipation), and Methyl salicylate-menthol ointment (used to treat minor muscle pain). b. Oxycodone (used to treat moderate to severe pain) 2.5 mg (milligrams), 1 or 2 tablets, every 6 hours as needed for pain. c. Potassium chloride (a supplement to replace potassium) 20 mEq (milliequivalent), 1 tablet daily. d. The wound care home instructions from the patient’s physician to the agency, dated 10/29/24, included a medication order for Silvadene cream (used to treat wound infection). 2. The Home Health Certification and Plan of Care (POC) for the certification period 7/16/24 through 9/13/24 and 9/14/24 and 11/12/24, and the medication profile, did not include Acetaminophen, Hydrocodone-acetaminophen, Hydroxyzine, Lactulose, Methyl salicylate-menthol ointment, or Silvadene cream. 3.The POC and the medication profile revealed: a. Oxycodone 5 mg, 1 tablet every 8 hours as needed for severe pain. b. Potassium chloride 10 mEq, 1 tablet daily. 4. There was no documentation in the clinical record of medication reconciliation of the discrepancies with the physician. C. Review of Patient 2’s clinical record revealed: 1.The order summary report from Southlake Village Rehabilitation and Care Center to the agency, dated 10/25/24, included medication orders for Miralax (used to treat constipation), Senna (used to treat constipation), Simethicone (used to treat stomach gas), Trolamine Salicylate cream (used to treat muscle and joint pain), and Tylenol. 2.The POC for the certification period of 10/28/24 through 12/26/24 and medication profile, included Vitamin B complex (vitamin supplement) which was not included on the order summary report from Southlake Village Rehabilitation and Care Center. 3.There was no documentation in the clinical record of medication reconciliation of discrepancies with the physician. D. Review of Patient 3’s clinical record revealed: 1.The orders from Health At Home Consultants to the agency, dated 10/21/24, included medication orders, Clotrimazole-Betamethasone cream (used to treat skin infection) and Melatonin (used to help with sleep). 2.The POC for the certification period 10/24/24 through 12/22/24 and the medication profile did not include Clotrimazole-Betamethasone cream and Melatonin. 3. There was no documentation in the clinical record of medication reconciliation of the discrepancies with the physician. E. Review of Patient 4’s clinical record revealed: 1.An updated medication list from Family Medicine at Nebraska Medicine to the agency, dated 9/10/24, included medication orders, Cetirizine (used to treat allergies), Cyanocobalamin (vitamin B supplement), Febuxostat (used to treat gout), Ipratropium (used to help with shortness of breath), Lidocaine ointment (used to treat pain), Liver oil-zinc oxide ointment (used to treat skin irritation), Magnesium citrate, Mag Oxide (magnesium supplement), Men’s 50 plus multivitamin (vitamin supplement), Metformin (used to treat diabetes), Narcan (used to treat narcotic overdose), and Nitroglycerin (used to treat chest pain). 2.The POC for the certification period 8/20/24 through 10/18/24 and 10/19/24 through 12/27/24, and the medication profile did not include, Cetirizine, Cyanocobalamin, Febuxostat, Ipratropium, Lidocaine ointment, Liver oil-zinc oxide ointment, Magnesium citrate, Mag Oxide, Men’s 50 plus multivitamin, Metformin, Narcan, or Nitroglycerin. 3.The agency requested an updated medication list from Patient 4’s physician, dated 9/9/24, and an updated medication list from Family Medicine at Nebraska Medicine to the agency, dated 9/10/24, included, Cetirizine, Cyanocobalamin, Febuxostat, Ipratropium, Lidocaine ointment, Liver oil-zinc oxide ointment, Magnesium citrate, Mag Oxide, Men’s 50 plus multivitamin, Metformin, Narcan, or Nitroglycerin. 4. An order from Nebraska Medicine to the agency, dated 9/25/24, included a medication order for Omadacycline (used to treat infections) 100 mg, Intravenous, every 24 hours for 6 weeks. This medication was not included on the POC for the certification period 10/19/24 through 12/27/24 or the medication profile. F. Review of Patient 7’s clinical record revealed: 1.Orders from Bryan Physician Network to the agency, dated 11/13/24, included a medication order for Tylenol, which was not included on the POC or medication profile. 2.During an interview on 11/19/24 at 4:05 PM, Patient 7 confirmed taking Tylenol, as needed for pain, and showed this surveyor a bottle of Tylenol in a drawer where Patient 7's medications were kept. G. Review of Patient 8’s clinical record revealed: 1.Order Summary Report from Ecumen Lakeshore to the agency, dated on 10/2/24, included medication orders for Meclizine (used to treat dizziness) and Melatonin (used to aid with sleep). 2. Review of POC for the certification period 10/11/24 through 12/9/24 and the medication profile did not include Meclizine or Melatonin. 3. The POC for the certification period 10/11/24 through 12/9/24 and the medication profile included Oxybutynin Chloride (a medication used to treat overactive bladder), and Tramadol, which was not included on the Order Summary Report. 4. There was no documentation in the clinical record of medication reconciliation of the discrepancies with the physician. H. Review of Patient 11’s clinical record revealed: 1.Discharge orders from Madonna Hospitals Lincoln to the agency, dated 7/23/24, included medication orders Bacitracin ointment (used to treat skin infections), Denosumab (used to treat bone problems), DSS/Senna (used to treat constipation), Lidocaine Gel (used to treat pain), and Polyethylene Glycol PEG (used to treat constipation). 2.The POC for the certification period of 7/24/24 through 9/21/24 and 9/22/24 through 11/20/24, the medication profile did not include orders Bacitracin ointment, Denosumab, DSS/Senna, Lidocaine Gel, or Polyethylene Glycol PEG. 3.There was no documentation in the clinical record of medication reconciliation of the discrepancies with the physician. I. Review of Patient 13’s clinical record revealed: 1.The Discharge Instructions from CHI Health Midlands to the agency, dated 5/21/24, included medication orders: a. Furosemide (used to treat fluid retention) 40 mg, orally, 1 tablet, 5 times weekly. b. Furosemide 40 mg, orally, 2 tablets, 2 times a weekly on Tuesday and Thursday. c. Gabapentin (used to treat nerve pain), 100 mg, orally, 2 capsules, 2 times a day in the morning and noon. d. Gabapentin 600 mg, orally, 1 tablet, every evening. e. Metoprolol tartrate (used to lower blood pressure) 50 mg, orally, 1 tablet, daily at night. 2. The Post Hospital Order Plan of Care, dated 5/21/24 and the medication profile, revealed: a. Furosemide 20 mg, orally, 2 tablets every morning. b. Gabapentin 100 mg, orally, 2 capsules every morning. 3. The agency failed to update the POC and the medication profile when new orders were received. J. Review of Patient 14’s clinical record revealed: 1.The Transition Orders and Information for the Continuation of Patient Care from Clarkson Hospital to the agency, dated 5/21/24, included medication orders: a. Midodrine (used to increase blood pressure) 10 mg, orally, 1 tablet, 3 times daily. b. Torsemide 100 mg, orally, 1 tablet, 4 times daily. 2. The patient medication profile, revealed: a. Torsemide 20 mg, orally, 1 tablet, daily. b. The Midodrine was not included. 3. The agency failed to update the patient medication profile when new orders were received. K. Review of Patient 16’s clinical record revealed: 1.The After Visit Summary from Bryan Health, dated 6/11/24 to the agency, included medication orders: a. Hydrocodone- Acetaminophen (used to treat moderate to severe pain), 5-325 mg, orally, 1 tablet, every 6 hours as needed for pain. b. Insulin Degludec (used to treat diabetes), inject 60 units (measurement of insulin), subcutaneously, daily. c. Methocarbamol (used to treat muscle spasms) 500 mg, orally, 2 tablets, 3 times daily. d. Bupropion XL (used to treat depression) 150 mg, orally, 1 tablet, daily. 2. The patient medication profile revealed: a. Hydrocodone- Acetaminophen 5-325mg, orally, 2 tablets, every 6 hours as needed for pain. b. Insulin Degludec, inject 50 units, subcutaneously, daily. c. Methocarbamol 750 units, orally, 1 tablet, 4 times a day as needed for muscle spasms. 3. The agency failed to update the medication profile when new orders were received. L. During an interview on 11/20/24 at 6:00 PM, the Back up Administrator confirmed, the agency failed to follow their policy and procedure to ensure the patient's medication orders on the Plans of Care and the medication profiles were accurate for Patients 1, 2, 3, 4, 7, 8, 11, 13, 14, 16.

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 record review, policy and procedure review, and complaint/grievance logs review, the agency failed to provide services as ordered on the plan of care for 1 of 18 records reviewed (Patient 18). The census was 225 (180 in the Omaha office and 45 in the Lincoln branch). A. Review of the agency's complaint/grievance logs revealed on 4/7/22 Patient 18 was expecting agency staff to arrive at the patient's home to draw labs at 8:00 AM. Agency staff notified Patient 18 that they were unable to draw labs at 8:00 AM as scheduled. Agency staff directed Patient 18 to travel to an outpatient clinic to have their labs drawn on 4/7/22. B. The agency failed to provide in-home services, as ordered, on 4/7/22 for Patient 18.

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 record review, policy and procedure review, the observation of the provision of cares, and staff interview, 5 of 7 agency staff observed during the provision of cares (Staff C, E, G, I, and H ) failed to follow the agency policies and procedures for hand hygiene/glove use and proper bag technique while providing cares to Patient 1, 2, 5, 6, and 7. The total sample size was 18. The census was 225 (180 in the Omaha office and 45 in the Lincoln branch). Findings are: A. Review of the agency’s policy and procedure titled Hand Hygiene, reviewed 10/1/20, revealed: 1.Hand hygiene was to occur before and after patient contact, before bag entry, before a procedure, and before and after donning gloves. 2.Gloves are to be used during all patient care activities that may involve exposure to blood and all other body fluids. B. Review of the agency’s policy and procedure titled Bag technique and Equipment Management, reviewed 10/1/20, revealed: 1.Hand hygiene must be performed prior to entering or re-entering the clinical bag. 2. All devices used, must be disinfected with a wipe. C. Review of Patient 1’s Home Health Certification and Plan of Care (POC), for the certification period 7/16/24 through 9/13/24 and 9/14/24 through 11/12/24, revealed orders for Physical Therapy to provide wound care 3 times weekly. D. During the observation of the provision of care for Patient 1, on 11/13/24 at 8:00 AM, Staff C failed to sanitize hands prior to applying gloves, on 3 separate occasions, when providing wound care treatment. E. Review of Patient 2’s POC, for the certification period 10/28/24 through 12/26/24, revealed orders for Occupational Therapy evaluation and equipment training. F. During the observation of the provision of care for Patient 2, on 11/13/24 at 12:00 PM, Staff E failed to sanitize hands prior to entering the bag on 2 separate occasions, when returning equipment into the bag. G. Review of Patient 5’s POC, for the certification period 10/11/24 through 12/9/24, revealed orders for Skilled Nursing (SN) to provide wound care 3 times weekly. H. During the observation of the provision of care for Patient 5, on 11/18/24 at 1:30 PM, Staff G failed to: 1.Remove gloves, sanitize hands, and apply new gloves, after cleaning a wound, and prior to applying a clean dressing to the wound. 2. Sanitize hands prior to entering the bag to obtain equipment. 3. Sanitize laptop after use and prior to placing the laptop back into the bag. I. Review of Patient 6’s POC, for the certification period of 11/5/24 through 1/3/25, revealed orders for SN to provide home health aide supervision every 14 days or less, overall body assessment, and for pain and medication management. J. During the observation of the provision of care for Patient 6, on 11/19/24 at 1:00 PM, Staff I failed to: 1.Sanitize laptop after use and prior to placing the laptop back into the bag. 2.Sanitize hands prior to entering the bag to obtain equipment for patient use. K. Review of Patient 7’s POC, for the certification period of 11/14/24 through 1/12/25, revealed orders for Physical Therapy (PT) to evaluate and treat. L. During the observation of the provision of care for Patient 7, on 11/19/24 at 3:00 PM, Staff H failed to sanitize hands prior to entering the bag to obtain equipment. M. During an interview on 11/20/24 at 6:00 PM, the Backup Administrator confirmed, the agency staff failed to follow the agency's policies and procedures for hand hygiene/glove use and proper bag technique while providing cares for Patients 1, 2, 5, 6, and 7.

Physicians Choice Home Health Care is in compliance with the requirements of 42 CFR 484.102 Condition of Participation for Home Health Agencies,

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to ensure that all treatments ordered by the physician included instructions specific to the treatment ordered for 1 of 17 clinical records reviewed (Patient 8). The total sample size was 17. The census was 169: 152 at the parent office and 17 at the branch office. Findings are: A. Review of the agency policy and procedure titled, Physicians Orders, reviewed 10/2021, revealed all orders for medications must contain the name of the drug, dosage, route of administration, and directions for use. Orders must be written completely…to avoid medication or treatment errors. The policy does not specify the parameters also apply to treatment orders. B. Review of the agency policy and procedure titled, Medication Orders, reviewed 9/2021, revealed the agency staff was to verify with the physician any incomplete, illegible, or unclear medication orders prior to administering. The policy does not specify the parameters also apply to treatment orders. C. Review of Patient 8’s clinical record revealed the Post Hospital Order dated 10/19/21 included: 1. Orders for Wound Vacuum negative pressure dressing changes 3 times per week, every Monday, Wednesday, and Friday if possible. (A wound vacuum is a therapeutic technique using a suction pump, tubing, and a dressing to remove excess exudate (wound drainage and materials) and promote healing). 2. The order did not include the pressure setting needed or the type of dressing/sponge to use in the wound bed. 3. There was no documentation in the clinical record to indicate the physician was contacted to clarify the order to include pressure settings and dressing type to be used. D. During an interview on 11/8/21 at 2:25 PM, the Administrator and the Director of Professional Services of the parent office (DOPS-Omaha) confirmed the wound vacuum orders did not include pressure settings and dressing type to use, and there was no documentation the agency contacted the physician to clarify the order.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on record review, policy and procedure review, and staff interview, the agency failed to include the patient’s progress towards the patient and agency identified goals and measurable outcomes on the revised/updated plan of care for 3 of 3 clinical records reviewed that included a revised/updated plan of care (Patient 5, 6 and 14). The total sample size was 17. The census was 169: 152 at the parent office and 17 at the branch office. Findings are: A. Review of the agency policy and procedure titled, Plan of Care, revised 8/2021, did not the requirement to include the patient’s progress towards the patient and agency identified goals and measurable outcomes on the revised/updated plan of care. B. Review of Patient 5’s clinical record revealed: 1. The patient’s start of care was 8/18/21. 2. The Home Health Certification and Plan of Care was revised/updated for the certification period of 10/17/21 through 12/15/21. 3. The revised/updated plan of care did not include the patient’s progress towards the patient and agency identified goals and measureable outcomes. C. Review of Patient 6’s clinical record revealed: 1. The patient’s start of care was 8/12/2020. 2. The Home Health Certification and Plan of care was revised/updated for the certification periods of 8/7/21 through 10/5/21 and 10/6/21 through 12/4/21 (the record review timeframe). 3. The revised/updated plans of care did not include the patient’s progress towards the patient and agency identified goals and measurable outcomes. D. Review of Patient 14’s clinical record revealed: 1. The patient’s start of care was 6/21/2020. 2. The Home Health Certification and Plan of care was revised/updated for the certification periods of 12/17/2020 through 2/14/21 and 2/15/21 through 4/15/21 (the record review timeframe). 3. The revised/updated plans of care did not include the patient’s progress towards the patient and agency identified goals and measurable outcomes. E. During an interview on 11/8/21 at 2:25 PM, the Administrator and the Director of Professional Services of the parent office (DOPS-Omaha) confirmed the revised/updated plan of care for Patient 5, 6, and 14 did not include patient’s progress towards the patient and agency identified goals and measureable outcomes.

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 record review, policy and procedure review, the observation of the provision of cares, and staff interview, 3 of 7 agency staff observed during the provision of cares (Staff H, C, and D) failed to follow the agency policies and procedures for the use of barriers and/or hand hygiene/glove use while providing cares to Patient 1, 6, and 5 respectively. The census was 169: 152 at the parent office and 17 at the branch office. Findings are: A. Review of the agency policy and procedure titled, Bag Technique and Equipment Management, revised 10/1/2020, revealed the policy was to ensure infection control measures are instituted when utilizing bag for supplies in the patient home. The policy revealed staff were to place a liner (barrier) between the supply bag and the floor or upholstered furniture. B. Review of the agency policy and procedure titled, Hand Hygiene, revised 10/1/2020, revealed hand hygiene was to occur before and after patient contact, before applying and removing gloves, before a procedure, before entering the supply bag, between dressing changes… C. Patient 1’s clinical record included orders for Skilled Nurse (SN), Physical Therapy (PT), and Occupational Therapy (OT). D. Patient 6’s clinic record included an order dated 11/2/21 for SN for wound care: 1. Left lateral ankle- cleanse wound…pat dry, apply hydrocel (an ointment) and Aquacel AG (a silver infused dressing used to cover a wound and deter infections in a wound)…, cover and wrap.... 2. Right lateral ankle- cleanse wound….pat dry, apply calmoseptine (an ointment used to protect skin from excess moisture), apply Aquacel AG…cover, wrap…secure… E. Patient 5’s Home Health Certification and Plan of Care for the certification period of 10/17/21 through 12/15/21 included orders for SN 1 time per week for wound care to cleanse wound…apply Aquacel AG…, and cover…. F. During the observation of cares of Patient-1 by Staff-H on 10/28/21 at 1:00 PM, Staff-H was observed to place supply bag and back pack directly on the carpeted floor in the patient’s home without the use of a barrier. G. During the observation of the provision of wound cares to Patient- 6 by Staff- C on 11/3/21 at 2:00 PM, Staff-C: 1. Contaminated the tip of the ointment tube by touching the tip of the tube to apply ointment to a gloved finger after previously applying ointment to the peri-wound (skin directly surrounding an open wound) with the same gloved finger. The nurse failed to change gloves and sanitize hands between applications of the ointment. 2. Failed to sanitize hands after removing gloves after completing wound care to right lateral ankle and prior to applying a new pair of gloves to complete wound care to left lateral ankle. H. During the observation of the provision of wound cares to Patient- 5 by Staff-D on 11/3/21 at 3:10 Pm, Staff- D failed to changes gloves and sanitize hands: 1. After removing a soiled dressing from a wound and prior to cleansing the wound 2. After cleansing the wound and prior to applying a clean dressing to the wound. I. During an interview on 11/8/21 at 2:25 PM, the Administrator and the Director of Professional Services of the parent office (DOPS-Omaha) confirmed Staff C, D, and H failed to follow the agency policy and procedures for hand hygiene, barrier use/bag technique, and glove use, providing the opportunity to spread potentially infectious bacteria.

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review, policy and procedure review, observation of the provision of cares, and staff interview, the agency failed to follow the agency policy and procedure to ensure the home health aide (HHA) plan of care (POC) was individualized to meet the patient’s specific care needs for 3 of 4 patients reviewed who received HHA services (Patient 4, 9, and 12). The total sample size was 17. The census was 169: 152 at the parent office and 17 at the branch office. Findings are: A. Review of the agency policy and procedure titled, Home Health Aide Care Plan, revised 10/2021, revealed: 1. A complete and appropriate care plan will be developed. 2. Was to provide documentation that the care is individualized to the patient specific needs. 3. The HHA POC was to be updated upon modifications or changes in the patient’s care. B. Review of Patient 4’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/26/21 through 12/24/21 include orders for HHA services 1 time a week for one week, then 2 times a week for 2 weeks to perform/assist with personal care and activities of daily living (ADL”s) according to the HHA POC developed by the registered nurse (RN). 2. The patient was admitted for surgical aftercare following surgery on the circulatory system. The patient had a new pacemaker placed. 3. A verbal order was received on 10/26/21 with instructions to follow post-pacemaker placement including: do not shower or get site (left upper chest) wet, do not raise left arm above should for 6 weeks, do not rub the wound or try to clean the steri-strips (strips used to hold incision together), no lotions, creams, or ointments on the wound site, and to report sings of bleeding, infection- drainage, swelling, redness, or fever. 4. The Aide Care Plan developed by the RN included shampoo hair, each visit, shower per patient request, partial bath/sponge bath per patient request. The care plan did not include any of the post pacemaker placement instructions. The RN documented the HHA was instructed on the patients plan of care. C. During the observation of cares to Patient 4 by the HHA on 11/2/21 at 12:30 PM, the HHA did shampoo the patient’s hair at the sink and assisted the patient with tub bath to prevent getting the wound wet, discussed with the patient that no lotion could be applied to the wound site, and provided reminders about the precautions. D. Review of Patient 9’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/12/21 through 12/10/21 included orders for HHA 1 time a week for 4 weeks to perform/assist with personal care and ADL’s according to the HHA POC established by the RN. 2. The patient has diagnoses of, but not limited to diabetes, gastrointestinal hemorrhage (bleeding), and uses antiplatelet medication (used to help prevent blood clots). 3. All tasks assigned to the HHA on the Aide Care Plan developed by the RN were assigned “as needed”. Tasks include assist to dress, check pressure areas, comb hair, pericare, shampoo hair, skin care shower change linens, and make bed. The HHA POC did not include any instructions to the aide for reporting changes noticed by the HHA during the provision of cares such as changes in skin (due to diabetes), bleeding (due to diagnoses of gastrointestinal bleed and antiplatelet medication use). E. Review of Patient 12’s clinical record revealed: 1. The Home Health Certification and Plan of Care for the certification period of 10/6/21 through 12/4/21 included orders for HHA 1 time a week for 4 weeks to perform/assist with personal care and ADL’s according to the HHA POC established by the RN. 2. The patient has diagnoses includes diabetes. 3. All tasks assigned to the HHA on the Aide Care Plan developed by the RN were assigned “as needed” except shower was assigned as every visit. Tasks include assist to dress, comb hair, complete bath, partial bath/sponge bath, pericare, shampoo hair, skin care, and tub. The HHA POC did not include any instructions to the aide for reporting changes noticed by the HHA during the provision of cares such as changes in skin (due to diabetes). F. During an interview on 11/8/21 at 2:25 PM, the Administrator and the Director of Professional Services of the parent office (DOPS-Omaha) confirmed the plan of care developed by the RN for patient 4, 9, and 12 were not specific to the patient’s care needs. The Administrator further confirmed the use of “as needed” for all tasks assigned to the HHA is “not what is expected” by the agency when developing the HHA POC.