Every finding on record at Torrance Memorial Medical Center

The following reflects the findings of the California Department of Public Health during a Complaint Validation Survey conducted from 12/17/2024 to 12/20/2024. Complaint Number: 110939 Active Patients: 576 Sample Size - 17 Home visit- 7 On 12/19/2024 at 12 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Home Health Agency’s (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) Director of Patient Care Services (DPCS), related to failure to review and maintain an accurate and current medication profile (a comprehensive record of all the medications that a patient is currently prescribed ) for one of 17 sampled patient (Patient 1). As a result, Patient 1 was placed at increased risk of confusion with the care and services provided to Patient 1 with regards to medication administration, ineffective drug therapy (failure of drug treatment due to inappropriate drug or dosage), non-compliance with drug therapy (a patient who does not take a prescribed medication or follow a prescribed course of treatment), and adverse drug reaction (unwanted undesirable effects that are possibly related to a drug) that could lead to hospitalization and death. On 12/19/24, at 6:25 p.m., the HHA submitted an IJ removal plan (IJRP-includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death of a patient likely), however, and upon review on 12/20/24, at 8:10 a.m., the IJRP was not accepted. On 12/20/2024, at 4 p.m., the Department completed the survey tasks and conducted an exit conference in the presence of the DPCS with the IJ situations not removed. On 1/10/2025 the agency submitted an IJ removal plan, reviewed and was accepted. The IJ removal plan indicated: The agency must have a system in place to ensure clinical oversight is provided for patient care and personnel to prevent Patient 1 from serious harm that could lead to hospitalization and death. Registered Nurse: Correct the patient's medication profile 12.18.2024. RN conducting visit on December 18, 2024, reviewed medications in the patient's home with the caregiver, clinical manager, and health facilities evaluator nurse. Verbal orders were submitted to the physician's office to confirm and correct the patient's medications. Lead Registered Nurse: Provide the patient with an accurate medication profile & confirm the patient/ caregiver's understanding of medications. 12.19.2024. A lead RN made a home visit to patient 1 to deliver and review the updated medication profile. The patient and the caregiver's understanding of medications was confirmed. Home Health Administrator: Review practices and standards with specific clinicians 12.30.2024. The clinical manager and Home Health Administrator reviewed the findings and documentation related to patient 1 with selected clinicians beginning December 23, 2024. Immediate action should be taken to ensure that patient 1 did not suffer adverse consequences due to the facility's failure to administer medications in accordance with professional standards. Director of Patient Care Services Focused chart 12.19.2024 review. The Director of Patient Care Services reviewed Patient I's chart and there were no untoward findings related to labs or vital signs and the patient was not hospitalized since his June admission due to these medication discrepancies. Immediate action should be taken to assess whether other patients In the agency are also affected by any similar medications administration errors related to failure to properly check medications provided against the pharmacy label. Ad Hoc Home Health Management Committee Review & update the medication reconciliation standard operating procedure12.19.2024. The Ad Hoc Home Health Management Committee met and updated the Standard Operating Procedure Titled Medication Reconciliation. The following updates were made: Steps 1 and 2 were edited for clarity and additional disciplines were added to the responsible party. Step 4: The physician will be notified if the patient is not taking medications as prescribed. Director of Patient Care Services Communicate to all clinicians the importance of medication reconciliation 12.19.2024. An ad hoc staff meeting was led by the Director of Patient Care Services, Educator/Staff Development Manager, and VP of Quality of Torrance Memorial. Preliminary medication reconciliation findings and action items were discussed. The revised Standard Operating Procedure Titled Medication Reconciliation was communicated to all staff members. Educator/Staff Development Manager Communicate revised medication reconciliation standard operating procedure to all clinicians 12.23.2024. Transitions of Care Pharmacy Manager Educate clinicians on medication reconciliation 12.31.2024. Torrance Memorial Medical Center's Transitions of Care Pharmacy Manager designed and delivered medication reconciliation training sessions targeted for home health clinicians. The training included education and practice sessions. Training began December 24, 2024 (See Attachment C) The Transitions of Care Pharmacy Manager is a board-certified geriatric pharmacist with over 20 years of experience. (See Attachment D) The training was completed for active personnel Tuesday, December 31st. (See Attachment E). Clinical Managers The medication profile of every patient will be reviewed and updated 12.31.2024. In order to assure the safety of all patients. The agency completed medication reconciliation and obtained signed attestations for all active patients on census as of December 17, 2024 with the following exceptions (Attachment F): ● Per surveyor correspondence discharged patients (Attachment G) ● Patients in transfer/ hold status: patients receiving care in an alternate care setting (i.e. hospital, skilled nursing facility, etc.) ● Patients who refused visits During medication reconciliation, patients &/or their caregivers signed an attestation, noting that medications were reviewed and are correct. (Attachment H). Home Health Administrator Increase monitoring and oversight of the medication reconciliation process. 12.31.2024. In order to assure continued compliance with the agency's medication reconciliation process, clinical leaders will perform 20 tracer visits per month beginning January 1, 2025, yielding, 60 tracer visits per quarter. During the tracer visits leaders will observe the medication reconciliation process. Performance will be measured based on the thoroughness of medication reconciliation. Just in time coaching will be provided by the observer based on the results of this activity. Results will be aggregated on a monthly basis as part of the Q.A/PI process. These results will be reported to the home health staff, the home health Quality and Performance Improvement Committee, Torrance Memorial Medical Center Performance Improvement and Patient Safety Council, and the TMMC. Governing Board Performance Improvement Committee. The Home Health Administrator is responsible for the implementation and monitoring of the medication reconciliation process. On 1/10/2025 the survey team conducted an onsite verification of the IJ removal plan. The IJ was removed on 1/10/2025 at 12:30 p.m., in the presence of the agency's Administrator. The following Conditions of Participation were not met: 484.54 Condition of participation: Comprehensive assessment of Patients. 484.60 Condition of participation: Care planning, coordination of services, and quality of care.

Comprehensive Assessment of Patients CFR(s): 484.55 Condition of participation: Comprehensive assessment of patients. Each patient must receive, and an HHA must provide, a patient-specific, comprehensive assessment. For Medicare beneficiaries, the HHA must verify the patient's eligibility for the Medicare home health benefit including homebound status, both at the time of the initial assessment visit and at the time of the comprehensive assessment. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) failed to ensure the Condition of Participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs for Comprehensive Assessment of Patients was met as follows: Findings The HHA failed to review and maintain an accurate and current medication profile (a comprehensive record of all the medications that a patient is currently prescribed) for one of 17 sampled patient (Patient 1). Licensed Vocational Nurse 1 (LVN 1) did not perform a medication reconciliation (the process of comparing a patient's medication orders to all the medications that the patient has been taking) nor checked all prescribed medications of Patient 1 during patient care visits. As a result, Patient 1 was placed at increased risk for medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and adverse medication reactions (unwanted undesirable effects that are possibly related to a drug) from the medications that could lead to hospitalization and death. (Refer to G536). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal regulation for Comprehensive Assessment of Patients Care planning which are provided to the patients who were assessed to receive home health care services.

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, an organization that delivers skilled nursing and other therapeutic services to a patient at home) failed to review and maintain an accurate and current medication profile (a comprehensive record of all the medications that a patient is currently prescribed) for one of 17 sampled patients (Patient 1). Licensed Vocational Nurse 1 (LVN 1) did not perform a medication reconciliation (the process of comparing a patient's medication orders to all the medications that the patient has been taking), nor check all prescribed medications for Patient 1 during patient care visits. As a result, Patient 1 was placed at increased risk for medication errors (any preventable event that may cause or lead to inappropriate medication use or patient harm) and adverse medication reactions (unwanted undesirable effects that are possibly related to a drug) from the medications that could lead to hospitalization and death. On 12/19/2024 at 12 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Home Health Agency’s (HHA, an organization that delivers skilled nursing and other therapeutics service to a patient at home) Director of Patient Care Services (DPCS), related to failure to review and maintain an accurate and current medication profile (a comprehensive record of all the medications that a patient is currently prescribed ) for one of 17 sampled patient (Patient 1). As a result, Patient 1 was placed at increased risk of confusion with the care and services provided to Patient 1 with regards to medication administration, ineffective drug therapy (failure of drug treatment due to inappropriate drug or dosage), non-compliance with drug therapy (a patient who does not take a prescribed medication or follow a prescribed course of treatment), and adverse drug reaction (unwanted undesirable effects that are possibly related to a drug) that could lead to hospitalization and death. On 12/19/24, at 6:25 p.m., the HHA submitted an IJ removal plan (IJRP-includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death of a patient likely), however, and upon review on 12/20/24, at 8:10 a.m., the IJRP was not accepted. On 12/20/2024, at 4 p.m., the Department completed the survey tasks and conducted an exit conference in the presence of the DPCS with the IJ situations not removed. Findings During a review of Patient 1's Patient Information, the Patient Information indicated, Patient 1's start of care (SOC) date was 6/20/2024, with diagnosis that included type two diabetes mellitus (DM- a chronic [long term] disease that occurs when the body can't control blood sugar levels) with foot ulcer (an open wound on the foot). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period of 10/18/2024 to 12/16/2024, Patient 1's Home Health Certification and Plan of Care indicated an order for skilled nurse (SN) home visits of three times a week for three weeks. for recertification evaluation, wound management, knowledge on disease process and management, medication, and compliance. The SN was also to instruct Patient 1 of signs and symptoms of adverse reaction to report to medical doctor (MD). Patient 1's Home Health Certification and Plan of Care indicated a physician's order of the following: 1. Furosemide (medication used to treat fluid retention) 20 milligrams (mg-unit of measure) one tablet (tab) oral daily with an order date of 6/20/2024. 2. Lisinopril (medication use to treat high blood pressure) 40 mg one tab daily with an order date of 6/20/2024. 3. Metformin (medication used to treat diabetes) 500 mg one tab twice daily with an order date of 6/20/2024. 4. Vitamin C (a vitamin that helps fight infections, heal wounds, and keep tissues healthy 1000 mg one tab daily with an order date of 6/20/2024. 5. Omega 3 (Healthy fats that support heart health) 350 mg one capsule daily 6. Iron (supplement used to treat or prevent low blood levels of iron) 150 mg one capsule daily for supplement with an order date of 6/20/2024. During a home visit on 12/18/2024, at 11:30 a.m., with Registered Nurse 1 (RN 1), Patient 1 was observed sitting on a couch in the living room with both lower extremities appeared swollen. RN 1 was observed assessing the patient’s edema and checking the pedal pulses. During an interview with RN 1 on 12/18/2024, at 11:40 a.m., RN 1 stated the patient had pitting edema +2 on lower leg and right foot and pedal pulses were present. While checking Patient 1’s medication with RN 1, the following medications were found: 1. Furosemide 20 mg one tab oral daily as needed. with a fill date (the date it was dispensed by the pharmacy) of 6/28/2024. 2. Lisinopril 20 mg one tab daily with a fill date of 11/21/2024. 3. Metformin 500 mg one tab twice daily with a fill date of 7/29/2024. 4. Vitamin C 1200 mg one tab daily 5. Omega 3 1200 mg one capsule daily. 6. Iron 65 mg one capsule daily. 7. Gabapentin (medication used to treat seizures) 100 mg one capsule three times daily with a fill date of 7/8/2024. 8. Oxycodone (medication used to treat pain) 5-325 mg one tab every six hours as needed for pain with an expiration date of 4/2024 During an interview with Family Member 1 (FM 1) on 12/18/2024, at 12 p.m., FM 1 stated she (FM 1) administers the following medications to Patient 1: a. Furosemide 20 mg one tab daily. FM 1 stated she (FM 1) has been giving Patient 1 the Furosemide medication daily for the last three months. b. Metformin 500 mg ½ tab twice daily. FM 1 stated that she (FM 1) has been giving Patient 1 Metformin 500mg ½ tablet medication twice daily for the past three months because Patient 1’s blood sugar reading were “under control” (normal range for blood sugar is 70 to 90 milligrams per deciliter (mg/dL-unit of measure). c. Lisinopril 20 mg one tab daily. FM 1 stated she (FM 1) has been giving Patient 1 Lisinopril 20 mgs once daily since 11/2024. d. Vitamin C 1200 mg one tab daily. FM 1 stated she (FM 1) bought the Vitamin C through an online vendor and FM 1 has been giving Vitamin C 1200mg supplement to Patient 1 for the past three months. e. Omega 3 1200 mg one capsule daily. FM 1 stated she (FM 1) bought the Omega 3 through an online vendor and FM 1 has been giving Omega 3 to Patient 1 for the past three months. f. Iron 65 mg one capsule daily. FM 1 stated she (FM 1) bought the Iron supplement through an online vendor and FM 1 has been giving Iron 65mg to Patient 1 for the past three months. g. Oxycodone 5-325 mg one tab as needed. FM 1 stated she (FM 1) has been giving Patient 1 the Oxycodone medication every night for the last seven days due to leg pain. FM 1 also stated she (FM 1) was not aware that the Oxycodone medication FM 1 had been administering to Patient 1 was expired. h. Gabapentin 100 mg one capsule three times daily. During an interview, FM 1 stated she (FM 1) has been giving Patient 1 the Gabapentin medication since 7/2024. FM 1 further stated that during the skilled nurse home visits, LVN 1 does not check Patient 1’s medications. FM 1 stated that the LVN 1 will only check Patient 1’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and provide wound care. During an interview on 12/18/2024, at 1 p.m. with RN 1, RN 1 stated that LVN 1 should be checking Patient 1’s medication during each skilled nurse home visits. RN 1 also stated that Patient 1 was not taking the correct medication as ordered because LVN 1 was not checking Patient 1’s medications, and the FM 1was not provided with teaching on Patient 1’s medication regimen. RN 1 further stated that LVN 1 should be checking the patient’s medications for expiration date because once a medication expires, it may no longer be safe or effective to use due to reduced potency (effect) or harmful side effects. During an interview on 12/20/2024, at 12 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that LVN 1 should always check the actual medication bottles of Patient 1 at every visits. DPCS stated that by administered Patient 1 with expired medications, it can result in ineffective drug therapy as the medications may have lost their potency (the strength, effectiveness, or power of something or someone). DPCS further stated that by administering medications at a lesser dosage than prescribed, it can also lead to ineffective drug therapy. DPSC stated that by administer medications not prescribed for Patient 1, it increases the risk that Patient 1 can experience drug to drug interaction (occurs when two or more drugs react with each other, causing the body to experience an unexpected side effect or change in how the drug works) or adverse drug reactions. A review of the agency’s policy "Medication Reconciliation" revised date 6/7/2024, indicated medication reconciliation will be conducted at each skilled visit, to do medication interaction by physically obtaining and reviewing each medication bottle, checking that dosing and indications are correct, and to compare the medication information the patient is currently taking with the medications ordered for the patient in order to identify and resolve discrepancies.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Care planning, coordination, quality of care as follows: The HHA failed to include diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels) management in the plan of care (POC, a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for three of 17 sampled patients (Patient 1, Patient 11, and Patient 12). This failure had the potential to result in a lack or delay in delivery of necessary care and services for Patient 1, Patient 11, and Patient 12.(Refer to G574) The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal regulation for Care planning, coordination, quality of care and had the potential to result in a lack or delay in delivery of necessary care and services for Patient 1, Patient 11, and Patient 12.

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) failed to include diabetes (a group of diseases that result in too much sugar in the blood) management in the plan of care (POC, a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for three of 17 sampled patients (Patient 1, Patient 11, and Patient 12). This failure had the potential to result in a lack or delay in delivery of necessary care and services for Patient 1, Patient 11, and Patient 12. a. During a review of Patient 1's Patient Information, the Patient Information indicated, Patient 1's start of care (SOC) date was 6/20/2024, with diagnosis that included type two diabetes mellitus (DM- a chronic [long term] disease that occurs when the body can't control blood sugar levels) with foot ulcer (an open wound on the foot). During a review of Patient 1’s RN (registered nurse) Recertification Assessment form, dated 12/13/2024, the RN recertification assessment indicated Patient 1’s comorbidities (a disease or medical condition that is simultaneously present with another condition) included IDDM (or insulin-dependent diabetes mellitus, a lifelong condition where the pancreas makes little or no insulin, which leads to high blood sugar levels). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period of 10/18/2024 to 12/16/2024, Patient 1's Home Health Certification and Plan of Care indicated an order for skilled nurse (SN) home visits of three times a week for three weeks. for recertification evaluation, wound management, knowledge on disease process and management, medication, and compliance. The SN was also to instruct Patient 1 of signs and symptoms of adverse reaction to report to medical doctor (MD). Patient 1's Home Health Certification and Plan of Care indicated a physician's order of the following: 1. Furosemide (medication used to treat fluid retention) 20 milligrams (mg-unit of measure) one tablet (tab) oral daily with an order date of 6/20/2024. 2. Lisinopril (medication use to treat high blood pressure) 40 mg one tab daily with an order date of 6/20/2024. 3. Metformin (medication used to treat diabetes) 500 mg one tab twice daily with an order date of 6/20/2024. During a home visit on 12/18/2024, at 11:30 a.m., with Registered Nurse 1 (RN 1), Patient 1 was observed sitting on a couch in the living room with both lower extremities appeared swollen. RN 1 was observed assessing the patient’s edema and checking the pedal pulses. During an interview with RN 1 on 12/18/2024, at 11:40 a.m., RN 1 stated the patient had pitting edema +2 on lower leg and right foot and pedal pulses were present. During an interview with Family Member 1 (FM 1) on 12/18/2024, at 12 p.m., FM 1 stated she (FM 1) has been giving Patient 1 Metformin 500mg ½ tablet medication twice daily for the past three months because Patient 1’s blood sugar reading were “under control” (normal range for blood sugar is 70 to 90 milligrams per deciliter (mg/dL-unit of measure). During an interview and record review, on 12/20/2024 at 11:35 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1’s current care plan. The DPCS confirmed Patient 1’s plan of care did not have specific care plan which included goals and interventions for diabetic management. b. During a review of Patient 11’s Face sheet, the face sheet indicated a Start Of Care (SOC) date of 8/1/2024, with a principal diagnosis of Pressure ulcer of sacral region stage 4 (skin breakdown that develops over a bony prominence located at the base of the spine due to prolonged pressure on that area and is most severe exposing the underlying muscle, tendon, or bone), and a pertinent diagnosis of Type 2 Diabetes Mellitus with diabetic peripheral angiopathy without gangrene (a chronic condition of high blood sugar levels that cause damage to blood vessels, particularly in the legs and feet). During a review of Patient 11’s Home Health Care Certification and Plan Of Care (POC, a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for the certification period of 11/29/2024 to 1/27/2025, the POC indicated an order for Patient 11 to have Skilled Nursing (SN) frequency of once a week for one week, twice a week for eight weeks, and once a week for one week, and four as needed (PRN) visits for falls, shortness of breath (SOB), uncontrolled pain, woundvac dressing complications, signs and symptoms of infection, skin breakdown, medication complications and unstable vital signs. During a joint home visit on 12/19/2024 at 11:40am with Registered Nurse 2 (RN 2), at Patient 11’s home, Patient 11 was observed laying in a hospital bed awake, alert and oriented to self. RN 2 was observed asking Patient 11’s family member for Patient 11’s blood sugar level for that visit. Patient 11’s family member was observed using his personal cell phone to scan Patient 11’s left upper arm continuous glucose (sugar) monitor to get Patient 11’s blood sugar level for RN 2. Patient 11’s family member stated to RN 2 that Patient 11’s blood sugar level read at 145, and RN 2 was observed typing that value into tablet. RN 2 stated he does not check Patient 11’s blood sugar level, but during home visits, he will ask Patient 11’s family member to provide him with Patient 11’s blood sugar level that they get from scanning the continuous monitor on Patient 11’s arm and he will document it on his notes. During a concurrent interview and record review on 12/20/2024 at 11:15am with the Director Of Patient Care Services (DPCS), Patient 11’s Care Plans were reviewed. Patient 11’s Care Plans indicated there was no formulated or documented Care Plan for Patient 11’s other pertinent diagnosis of Type 2 Diabetes Mellitus. The DPCS stated and confirmed that there was no documented or formulated Care Plan for Patient 11’s Type 2 Diabetes Mellitus in the medical records. During a concurrent interview and record review on 12/20/2024 at 11:20am with the DPCS, Patient 11’s Skilled Nursing Visit Notes with dates of 12/4/2024, 12/7/2024, and 12/14/2024 were reviewed. Patient 11’s Skilled Nursing Visit Notes did not indicate the Skilled Nurse (SN) assessed or documented Patient 11’s blood sugar levels during those visits. The DPCS stated and confirmed that there was no documented evidence that the SN assessed Patient 11’s blood sugar levels during the home visits of 12/4/2024, 12/7/2024, and 12/14/2024. The DPCS further stated the patient or caregiver will check the blood sugar at home and the SN should ask the patient or caregiver what the blood sugar level during home visits was. c. During a review of Patient 12’s Face sheet, the face sheet indicated a Start Of Care (SOC) date of 11/1/2024, with a principal diagnosis of Neoplasm related pain (pain caused from Cancer). During a review of Patient 12’s Home Health Care Certification and Plan Of Care (POC, a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for the certification period of 11/1/2024 to 12/30/2024, the POC indicated an order for Patient 12 to have Skilled Nursing (SN) frequency of twice a week for four weeks, and once a week for two weeks, and four as needed (PRN) visits for uncontrolled pain, shortness of breath (SOB), low oxygen level, hypoglycemia (low blood sugar level), falls, and skin breakdown. During a review of Patient 12’s Medication Profile, undated, the medication profile indicated an order for the following: 1. Insulin Lantus Solostar Pen (long acting insulin to control high blood sugar) 100 units/milliliters (ml) subcutaneous (under the skin) solution; inject 10 units subcutaneous once a day (at bedtime) for diabetes 2. Metformin 500 milligrams (mg) oral tablet; take 1 tablet orally 2 times a day, once in the am, once in the pm for diabetes During a joint home visit on 12/18/2024 at 11:46 am with Registered Nurse 2 (RN 2), at Patient 12’s home, Patient 12 was observed sitting up in a recliner chair in the living room, awake, alert, and oriented to person, place, time and date. Patient 12 was observed wearing a nasal cannula (medical device that provides supplemental oxygen through two prongs that fit into the nostrils), with a long connector tube connected to oxygen concentrator at 3.5 liters/minute. Patient 12 stated he checks his blood sugar levels twice a day via his continuous glucose (sugar) monitoring device on his right upper arm and administers his insulin. RN 2 was not observed assessing Patient 12’s blood sugar level or ask Patient 12 what his blood sugar level during the home visit was. During a concurrent interview and record review on 12/20/2024 at 11: 25am with the Director Of Patient Care Services (DPCS), Patient 12’s Care Plans were reviewed. Patient 12’s Care Plans indicated there was no formulated or documented Care Plan for Patient 12’s other pertinent diagnosis of Type 2 Diabetes Mellitus. The DPCS stated and confirmed that there was no documented or formulated Care Plan for Patient 12’s Type 2 Diabetes Mellitus in the medical records. During a concurrent interview and record review on 12/20/2024 at 11:30am with the DPCS, Patient 12’s Skilled Nursing Visit Notes with dates of 12/12/2024 and 12/16/2024 were reviewed. Patient 12’s Skilled Nursing Visit Notes did not indicate the Skilled Nurse (SN) assessed or documented Patient 12’s blood sugar levels during those visits. The DPCS stated and confirmed that there was no documented evidence that the SN assessed Patient 12’s blood sugar levels during the home visits of 12/4/2024, 12/7/2024, and 12/14/2024. The DPCS further stated the patient or caregiver will check the blood sugar at home and the SN should ask the patient or caregiver what the blood sugar level during home visits was. During a review of the Home Health Agency’s (HHA) Policy and Procedure (P&P) titled, Care Planning Process, with a revised date of November 2024, indicated that an individualized plan of care is a patient specific clinical plan of care that includes all pertinent diagnosis, mental status, types of services/equipment, frequency of visits, goals and interventions, and is developed by the clinician along with the physician and other involved disciplines based upon patient’s identified needs and review it with the patient, family/caregiver. The P&P further indicates that the Plan of care will include, but not limited to all patient care orders from all physicians involved in the plan of care, including verbal orders, and all pertinent diagnoses. Findings: a. During a review of Patient 1's Patient Information, the Patient Information indicated, Patient 1's start of care (SOC) date was 6/20/2024, with diagnosis that included type two diabetes mellitus with foot ulcer (an open wound on the foot). During a review of Patient 1’s RN (Registered Nurse) Recertification Assessment form, dated 12/13/2024, the RN Recertification Assessment indicated Patient 1’s comorbidities (a disease or medical condition that is simultaneously present with another condition) included IDDM (or insulin-dependent diabetes mellitus, a lifelong condition where the pancreas makes little or no insulin (helps your body turn food into energy and controls your blood sugar levels, which leads to high blood sugar levels). During a review of Patient 1's Home Health Certification and Plan of Care for the certification period of 10/18/2024 to 12/16/2024, Patient 1's Home Health Certification and Plan of Care indicated an order for skilled nurse (SN) home visits of three times a week for three weeks for recertification evaluation, wound management, knowledge on disease process and management, medication, and compliance. The Home Health Certification and Plan of Care indicated the SN was to instruct Patient 1 of signs and symptoms of adverse reaction (an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof) to report to medical doctor (MD). Patient 1's Home Health Certification and Plan of Care indicated a physician's order of the following: 1. Furosemide (medication used to treat fluid retention) 20 milligrams (mg-unit of measure) one tablet (tablet) oral daily with an order date of 6/20/2024. 2. Lisinopril (medication use to treat high blood pressure) 40 mg one tab daily with an order date of 6/20/2024. 3. Metformin (medication used to treat diabetes) 500 mg one tab twice daily with an order date of 6/20/2024. During a home visit on 12/18/2024, at 11:30 a.m., with Registered Nurse 1 (RN 1), Patient 1 was observed sitting on a couch in the living room with both lower extremities (both legs) were swollen. RN 1 was observed assessing Patient 1’s edema (swelling caused by too much fluid) and checking the pedal (top of the foot) pulses. During an interview on 12/18/2024, at 11:40 a.m., with RN 1, RN 1 stated Patient 1 had pitting (indentation) edema +2 (you see a light dent, but it goes away within 15 seconds) on the lower leg and right foot and pedal pulses were present. During an interview with Family Member 1 (FM 1) on 12/18/2024, at 12 p.m., FM 1 stated she (FM 1) would give Patient 1 Metformin 500mg half a tablet medication twice daily for the past three months because Patient 1’s blood sugar reading was “under control” (normal range for blood sugar is 70 to 90 milligrams per deciliter (mg/dL-unit of measure). During an interview and record review, on 12/20/2024, at 11:35 a.m., with the Director of Patient Care Services (DPCS), the DPCS reviewed Patient 1’s current care plan. The DPCS stated Patient 1’s plan of care did not have specific care plan that included goals and interventions for diabetic management. b. During a review of Patient 11’s Face sheet, the Face Sheet indicated a Start Of Care (SOC) date of 8/1/2024, with a principal diagnosis of Pressure ulcer (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) of sacral (tail bone) region stage 4 (are deep wounds that may impact muscle, tendons, ligaments, and bone) and a pertinent diagnosis of Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (death of body tissues due to lack of blood flow). During a review of Patient 11’s Home Health Care Certification and Plan Of Care (POC, a written plan that specifies scope, frequency, duration of services and a program of treatment or care) for the certification period of 11/29/2024 to 1/27/2025, the POC indicated an order for Patient 11 to have Skilled Nursing (SN) frequency of once a week for one week, twice a week for eight weeks, and once a week for one week, and four as needed (PRN) visits for falls, shortness of breath (SOB), uncontrolled pain, wound vac (is a method of decreasing air pressure around a wound to assist the healing dressing complications), signs and symptoms of infection, skin breakdown, medication complications and unstable vital signs (specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions). During a joint home visit on 12/19/2024, at 11:40 am, with Registered Nurse 2 (RN 2), at Patient 11’s home, Patient 11 was observed laying in a hospital bed awake, alert, and oriented to self. RN 2 was observed asking Patient 11’s family member for Patient 11’s blood sugar level for that visit. Patient 11’s family member was observed using his personal cell phone to scan Patient 11’s left upper arm continuous glucose (sugar) monitor to get Patient 11’s blood sugar level for RN 2. Patient 11’s family member stated to RN 2 that Patient 11’s blood sugar level read at 145, and RN 2 was observed typing that value into tablet. RN 2 stated he did not check Patient 11’s blood sugar level, but during home visits, he would ask Patient 11’s family member to provide him (RN2) with Patient 11’s blood sugar level that they get from scanning the continuous monitor on Patient 11’s arm and he would document it on his notes. During a concurrent interview and record review on 12/20/2024, at 11:15 am, with the Director of Patient Care Services (DPCS), Patient 11’s Care Plans were reviewed. The DPCS stated Patient 11’s Care Plans indicated there was no Care Plan for Patient 11’s diagnosis of Type 2 Diabetes Mellitus. The DPCS stated that there was no documented or formulated Care Plan for Patient 11’s Type 2 Diabetes Mellitus in the medical records. During a concurrent interview and record review on 12/20/2024, at 11:20 am, with the DPCS, Patient 11’s Skilled Nursing Visit Notes with dates of 12/4/2024, 12/7/2024, and 12/14/2024 were reviewed. The DPCS stated Patient 11’s Skilled Nursing Visit Notes did not indicate the Skilled Nurse (SN) assessed or documented Patient 11’s blood sugar levels during those visits. The DPCS stated there was no documented evidence the SN assessed Patient 11’s blood sugar levels during the home visits of 12/4/2024, 12/7/2024, and 12/14/2024. The DPCS stated the patient or caregivers (in general) would check the blood sugar at home and the SN should ask the patient or caregiver what the blood sugar level during home visits was. c. During a review of Patient 12’s Face sheet, the face sheet indicated a Start of Care (SOC) date of 11/1/2024, with a principal diagnosis of Neoplasm related pain (pain caused from Cancer). During a review of Patient 12’s Home Health Care Certification and Plan of Care for the certification period of 11/1/2024 to 12/30/2024, the POC indicated an order for Patient 12 to have Skilled Nursing (SN) frequency of twice a week for four weeks, and once a week for two weeks, and four as needed (PRN) visits for uncontrolled pain, shortness of breath (SOB), low oxygen level, hypoglycemia (low blood sugar level), falls, and skin breakdown. During a review of Patient 12’s Medication Profile, undated, the medication profile indicated an order for the following: 1. Insulin Lantus Solostar Pen (long acting insulin to control high blood sugar) 100 units/milliliters (ml) subcutaneous (under the skin) solution; inject 10 units subcutaneous once a day (at bedtime) for diabetes 2. Metformin 500 milligrams (mg) oral tablet; take 1 tablet orally two times a day, once in the am, once in the pm for diabetes. During a joint home visit on 12/18/2024, at 11:46 am, with Registered Nurse 2 (RN 2), at Patient 12’s home, Patient 12 was observed sitting up in a recliner chair in the living room, awake, alert, and oriented to person, place, time and date. Patient 12 was observed wearing a nasal cannula (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) connected to oxygen concentrator at 3.5 liters/minute. Patient 12 stated he (Patient 12) would check his blood sugar levels twice a day via his continuous glucose (sugar) monitoring device on his right upper arm and administers his insulin. RN 2 was not observed assessing Patient 12’s blood sugar level or ask Patient 12 what his blood sugar level during the home visit was. During a concurrent interview and record review on 12/20/2024, at 11: 25am, with the Director Of Patient Care Services (DPCS), Patient 12’s Care Plans were reviewed. The DPCS stated Patient 12’s Care did not have a Care Plan for Patient 12’s Type 2 Diabetes Mellitus in the medical records. During a concurrent interview and record review on 12/20/2024, at 11:30 am, with the DPCS, Patient 12’s Skilled Nursing Visit Notes with dates of 12/12/2024 and 12/16/2024 were reviewed. The DPCS stated there was no documented evidence that the SN assessed Patient 12’s blood sugar levels during the home visits of 12/4/2024, 12/7/2024, and 12/14/2024. The DPCS stated the patient or caregiver (in general) would check the blood sugar at home and the SN should ask the patient or caregiver what the blood sugar level during home visits was. During a review of the Home Health Agency’s (HHA) Policy and Procedure (P&P) titled, Care Planning Process, with a revised date of November 2024, indicated that an individualized plan of care is a patient specific clinical plan of care that includes all pertinent diagnosis, mental status, types of services/equipment, frequency of visits, goals and interventions, and is developed by the clinician along with the physician and other involved disciplines based upon patient’s identified needs and review it with the patient, family/caregiver. The P&P further indicates that the Plan of care will include, but not limited to all patient care orders from all physicians involved in the plan of care, including verbal orders, and all pertinent diagnoses.