Every finding on record at Yadkin Valley Home Health

An onsite, unannounced compliant investigation was conducted 4/22/24-4/23/24. The allegation related to nursing was not substantiated, however, deficiencies to the Medicare CoP were identified.

HHA can no longer meet the patient's needs CFR(s): 484.50(d)(1) The transfer or discharge is necessary for the patient's welfare because the HHA and the physician or allowed practitioner, who is responsible for the home health plan of care agree that the HHA can no longer meet the patient's needs, based on the patient's acuity. The HHA must arrange a safe and appropriate transfer to other care entities when the needs of the patient exceed the HHA's capabilities; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to assist the patient to find provider to meet needs when the patient was identified as needing a higher level or care for 1 of 1 patient discharged due to needing a higher level of care [#4]. The findings included: The policy, Discharge Criteria and Process [10/7/22] was provided by the assistant director on 4/23/24 at 11 am. The policy stated, "...The organization will verbally notify the patient of the decision to terminate or reduce services prior to the last scheduled visit...The decision to terminate or reduce services must be documented in the clinical record, citing the circumstances and notification to the patient...and the patient's physician." Patient # 4 had a Start of Care [SOC] date of 1/3/24 with an admitting diagnosis of pulmonary fibrosis [scarring of the lungs makes breathing difficult]. Review of the Plan of Care for the certification period 1/3/24-3/2/24 included orders for SN [skilled nursing] 1 time a week for 3 weeks, 1 time a week for 1 weeks, 1 time a week for 3 weeks, 1 time a week for 1 week [1 time a week for 8 weeks]. Review of the clinical record revealed RN #5 completed the SOC visit on 1/3/24. Review of the clinical record revealed LPN # 1 documented the following information on 1/11/24 for 1/8/24”Contacted patient to schedule appointment for 1/9/24...patient did finally agree to visit between 145 and 345 [sic]...” LPN # 1 completed a routine visit on /9/24 and documented the following information, “...Arrived at home, firetruck noted departing patient’s home...Call placed to EMS and they advised that patient received lift assist and patient was not transported...SN entered home...patient stated, ‘you are too late’...patient was asked if he would allow SN to perform visit, he stated ‘your place called the ambulance and I told them not to because I was on the floor’. Patient speaking very rudely to SN...Patient’s assistant arrived at the home and informed SN that patient had had two falls already today and that herself and her husband had come this am to assist patient off the floor...Call was placed to PCP’s office, spoke with ______, she was made aware of interaction with patient and probability of discharge due to patient refusal and unsafe environment...1/10/24 spoke with ______ at pcp [sic] office and she was made aware that patient will be discharged from services. She informed pcp [sic] as well.” Further review of the clinical record revealed the following documentation related to a phone call to Patient # 4 dated 1/14/24 for 1/12/24 by RN # 5, “...I told him I had some unfortunate news and told him with chart review it was determined that he needed a different level of care than we could provide. He raised his voice and said something like ‘who made that decision? And that was the wrong decision’...He said he would fight the decision...He asked for the number to call to appeal, and I reminded him of his admission booklet that details how to file a grievance...” Further review of the clinical record revealed RN # 5 completed a non-visit discharge on 1/13/24 and documented the following information on 1/14/24, “Non visit agency discharge completed due to patient’s willingness [sic] to comply with nursing visits...frequent falls. Patient was verbally aggressive to clinical staff when staff appropriately contacted EMS for assistance when patient reported he had fallen in the floor. Due to not having caregiver available on a regular basis to assist patient with meals and hygiene and fall prevention...Recommended to patient to seek higher lever of care, or to get personal care services such as _______ [name of agency]...” Review of the clinical record revealed no evidence the agency attempted to assist the patient in finding another agency which might be able to provide the higher level of care prior to discharge.

Advise the patient of discharge for cause CFR(s): 484.50(d)(5)(i) (i) Advise the patient, representative (if any), the physician(s) or allowed practitioner(s), issuing orders for the home health plan of care, and the patient's primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) that a discharge for cause is being considered; This ELEMENT is not met as evidenced by: Based on agency policy, clinical record review and staff interviews the agency failed to resolve non-compliance issues before discharging patient for cause for 1 of 2 discharged patients [#3]. The findings included: The policy, Discharge Criteria and Process [10/7/22] was provided by the assistant director on 4/23/24 at 11 am. The policy stated, "...The organization will verbally notify the patient of the decision to terminate or reduce services prior to the last scheduled visit...The decision to terminate or reduce services must be documented in the clinical record, citing the circumstances and notification to the patient...and the patient's physician." Patient # 3 had a Start of Care [SOC] date of 3/5/24 with admitting diagnoses of unspecified fracture of lower end of left tibia, acquired absence of right leg above the knee, and type 2 diabetes mellitus with diabetic chronic kidney disease. Review of the Plan of Care for the certification period 3/5/24-5/3/24 included orders for SN [skilled nursing] 1 time a week for 3 week and 1 time a week for 1 week. Review of the clinical record revealed RN # 3 completed the SOC visit on 3/5/24. LPN # 4 completed a routine visit on 3/12/24 and documented the following information, “...Patient has oxygen concentrator on and tubing in bed and is smoking cigarettes in bed beside of it. SN educated patient that he needs to turn off oxygen concentrator when he is smoking and remove tubing from bed. Educated no smoking in home due to oxygen, but family does smoke in the next room...FSBS [finger stick blood sugar] is supposed to be checked daily. Patient does not know his last FSBS because he has to [sic] been checking it. SN educated that he needs to check it daily since he does [sic] diabetic medication...Patient does not follow diabetic diet, patient had a 24 pack of mtn dew [sic] beside of bed...Medplanner filled for 2 weeks. Patient did not complete all medication that was in medplanner from last week because he states he was sick. SN educated patient to take all medication in medplanner and if not this would be non-compliance. LPN # 4 conducted the weekly visit scheduled for 3/21/24 and documented the following information, “...Educated no smoking in home due to oxygen, but family does smoke in next room while concentrator is on and running. Patient did smoke throughout the visit...FSBS is suppose [sic] to be checked daily. Patient reports he does not know what his last FSBS [sic] because he has not been checking it...No medication was missing from the medplanner and they did not need to be filled this visit. Patient did not take any medications that was in medplanner from last week...SN educated patient again to take all medication in medplanner again this time and if not this would be non-compliance and we would have to discharge...”Review of the medical record revealed no evidence the LPN contacted the RN or the physician to report compliance issues related to oxygen safety or diabetic precautions. Further review of the clinical record revealed RN # 3 completed a non-visit discharge on the patient dated 3/25/24 at 4:29 pm. Documentation on the discharge revealed the following information, “...NV [non-visit] discharge completed this date due to noncompliance...” Further review of the clinical record revealed RN # 3 documented the following communication with the physician on 3/25/24 at 4:30 pm, “Patient was discharged from agency today, no visit made r/t [related to] noncompliance...” There was no evidence the agency attempted to solve or address the issues related to non-compliance prior to discharging the patient for cause.

An onsite recertification and follow up survey was conducted 08/28/23-08/30/23. No deficiencies the the Emergency Preparedness Program were identified.

An onsite recertification and follow up survey was conducted 08/28/23-08/30/23. Deficiencies to the Medicare Conditions of Participation were identified.

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 clinical record review and staff interview, the agency failed to identify a patient with a fluid restriction during the initial assessment for 1 of 1 patient with a fluid restriction (#11). Findings included: Patient #11 was admitted on 8/1/23 with a diagnosis of congestive heart failure. The Plan of Care (POC) for 8/1/23-9/29/23 included orders for skilled nursing one time for one week, twice weekly for one week, then weekly for three weeks; physical therapy one time for one week, twice weekly for six weeks, then one time for one week. The POC included no dietary restrictions. On 8/8/23, LPN #5 documented the patient was on a 50-ounce fluid restriction. The home health referral from the hospital included diet orders as less than 200 mg sodium daily and less than 1.5-liter fluid restriction. An interview with LPN #5 on 8/28/23 at 8:30 a.m. revealed the patient told the LPN about the fluid restriction. An interview on 8/28/23 at 9:10 a.m. with RN #8 revealed the RN was unaware of the fluid restriction. An interview with the assistant administrator on 8/30/23 at 8:30 a.m. confirmed the fluid restriction was on the referral.

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 policy and procedure, observation, clinical record review, and patient/caregiver interviews, the agency failed to review all current medications for 6 of 7 patients that received a home visit (#12, 13, 11, 14, 9, and 6). Findings included: 3. Patient #11 was admitted on 8/1/23 with a diagnosis of congestive heart failure. The Plan of Care (POC) for 8/1/23-9/29/23 included orders for skilled nursing one time for one week, twice weekly for one week, then weekly for three weeks; physical therapy one time for one week, twice weekly for six weeks, then one time for one week. A joint home visit was conducted on 8/28/23 at approximately 2:00 p.m. with RN #8. A medication review was conducted with the patient during the visit. The following discrepancies were identified: · The POC included orders for Magnesium 64 mg daily as a supplement. The patient reported she took two tablets twice daily for “a couple of years.” · The POC included Duloxetine 20 mg, one capsule twice daily for depression. The patient reported she took two capsules twice daily “for 4-5 years.” · The POC included gabapentin 100 mg three times daily for pain. The patient reported she took twice daily. · The POC included furosemide 20 mg, two tablets daily for fluid retention. The patient reported she took one tablet daily which had begun approximately “two weeks ago.” · The patient reported taking Vitamin D 1000 units, take three tablets daily. Vitamin D was included on the patient’s hospital discharge medication list. But was not included on the POC. An interview with RN #8 during the home visit confirmed there were discrepancies between the patient report and the POC. 4. Patient #14 was admitted on 8/11/23 with diagnoses of an intestinal Escherichia coli (bacteria) infection, chronic obstructive pulmonary disease (COPD—lung disease), and type 2 diabetes mellitus. The Plan of Care (POC) for 8/11/23-10/9/23 included orders for physical therapy twice weekly for three weeks, then one time for one week. A home visit was conducted on 8/28/23 at 3:00 p.m. with PTA #10. A medication review was conducted with the patient during the visit. The following medication discrepancies were identified: · The patient reported taking Duloxetine (used for depression) 20 mg “every couple of days.” The patient had a prescription bottle dated 7/6/23 with instructions to take at bedtime. The medication was not included on the POC. · The patient reported putting Neosporin (antibiotic ointment) on buttocks four times per day for “2-3 months.” The medication was not included on the POC. PTA #10 confirmed during the home visit the medications were not included on the POC. 5. Patient #9 was admitted on 8/8/23 with a diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy (damage or disease affecting peripheral nerves). The Plan of Care (POC) for 8/8/23-10/6/23 included orders for skilled nursing one time per week for four weeks; physical therapy weekly for four weeks; and speech therapy twice weekly for eight weeks. A joint home visit was conducted with physical therapy assistant #7 on 8/29/23 at 8:00 a.m. A medication review was conducted with the patient during the visit. The following discrepancies were identified: · The POC included orders for Clonidine 0.2 mg 1 tablet three times daily for blood pressure. The patient reported she has taken 2 tablets three times daily for over a year. · The POC included orders for fluticasone 50 mcg/inhalation, inhale one puff twice daily for nasal allergies. The patient reported the medication was used once daily. · The POC included orders for Metoprolol Succinate ER 25 mg twice daily for blood pressure. The patient reported taking 50 mg daily. · Triamterene 37.5/HCTZ 25 mg twice daily for fluid retention was omitted from the POC. The prescription bottle was dated 6/30/23. · The POC included venlafaxine 75 mg, take two capsules twice daily for anxiety/depression. The patient reported she took two capsules in the morning and one capsule at lunch. A prescription bottle in the home dated 5/8/23 included those instructions. · The POC included orders for losartan 100 mg daily for blood pressure. The patient reported she took 50 mg. An interview with the PTA during the visit confirmed the POC and the patient report of medications contained discrepancies. 6. Patient #6 was admitted on 8/15/23 with diagnoses of cutaneous abscess (a localized collection of pus) of abdominal wall. The Plan of Care (POC) for 8/15/23-10/13/23 included orders for skilled nursing one time for one week, then twice weekly for eight weeks; physical therapy twice weekly for three weeks, then one time for one week. A joint home visit was conducted on 8/29/23 at 10 a.m. with LPN #14. A review of current medications was conducted with the patient during the visit. The patient reported taking Tylenol 325 mg 2 pills as needed for pain, a probiotic daily, and Vivarin daily for sluggishness. The medications were omitted from the POC. An interview with LPN #14 was conducted during the visit. The interview confirmed the medications were not included on the POC. A policy titled “Administration and Documentation of Medications,3-004.1” was provided by the agency director on 08/23/23 at 11:45 a.m. revised 11/07/19 revealed, “…as part of the assessment process, a drug history will be taken, and comparison made between the physician’s orders and the current medication the patient is taking…” 1.Patient #12 was admitted on 08/01/23 with diagnoses of type 2 diabetes, essential hypertension (high blood pressure), other disorders of the lung and anxiety disorder. The Plan of Care (POC) for 08/01/23-09/29/23 included the following orders: skilled nursing 1 time a week for 1 week, 1 time a week for 3 weeks, and 1 time a week for 1 week; physical therapy 2 times a week for 4 weeks and home health aide 1 time a week for 1 week, and 2 times a week for 4 weeks. A home visit was conducted on 08/29/23 at 3:12 p.m. with the registered nurse. A review of the current medications was conducted with the patient during the visit. The medication profile provided by the agency did not include the following medication: albuterol sulfate 2.5mg (milligrams) per 3 ml (milliliter) solution used in the patient’s nebulizer 3 times a day. The patient confirmed she has been using this treatment for 8 to 9 months. 2.Patient #13 was admitted on 08/11/23 with diagnoses of chronic lymphocytic leukemia (cancer in blood forming tissues), cognitive communication deficit and muscle weakness. The Plan of Care (POC) for 08/11/23 to 10/09/23 included the following orders: skilled nursing 3 times a week for 3 weeks, 1 time a week for 1 week; physical therapy 2 times a week for 4 weeks, and occupational therapy 1 time a week for 4 weeks. A home visit was conducted on 08/28/23 at 2:54 p.m. with the licensed practical nurse. A review of the current medications was conducted with the patient during the visit. The following discrepancy was identified during the home visit: vitamin d2 (supplement) 50,000 IU (international units) 1 capsule weekly on Mondays. The patient confirmed she has been taking the vitamin d2 for a couple of years.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on policy review, clinical record review, and staff interview, the agency failed to coordinate with the physician on needed equipment/medications/services for 2 of 17 patients (#14 and 17). Findings included: A policy, “Care Coordination” (approved 12/12/22), was provided by the assistance administrator on 8/30/23 at 11:19 a.m. The policy stated, “Written evidence of care coordination may be found in the plan of care, case conference summary forms, or clinical notes in the patient’s clinical record.” 1. Patient #14 was admitted on 8/11/23 with diagnoses of an intestinal Escherichia coli (bacteria) infection, chronic obstructive pulmonary disease (COPD—lung disease), and type 2 diabetes mellitus. The Plan of Care (POC) for 8/11/23-10/9/23 included orders for physical therapy twice weekly for three weeks, then one time for one week. The initial assessment was conducted on 8/11/23 by PT #9. The note stated, “Pt [patient] currently does not have a way to check her blood sugars in home. Pt does not currently have any levothyroxine {thyroid medication], linzess [used to treat constipation], or inhalers. “ There was no evidence of follow-up with the physician related to the medications after the initial assessment. There was no evidence of follow-up with the physician, after the initial assessment, to assist the patient in obtaining a glucometer until 8/28/23. On 8/16/23 PTA #14 visited the patient. The visit note stated, “Pt is going to MD this afternoon…Instructed pt to mention wound on buttock to MD and BLE [bilateral lower extremity] swelling…” PTA #10 conducted a visit on 8/21/23. The visit note stated that the patient had a small skin tear on buttock area and the buttocks were reddened. “PTA inquired about orders for SN.” An interview with the assistant administrator on 8/30/23 at 9:00 a.m., it was confirmed there was no evidence of follow-up on the medications. The interview also confirmed there was no follow-up on the glucometer or nursing order until 8/28/23. 2. Patient #16 was admitted on 8/2/23 with a diagnosis of pulmonary emboli (blood clot in lung). The Plan of Care (POC) for 8/2/23-9/30/23 included orders for physical therapy one time for one week, then twice weekly for three weeks. The initial assessment was conducted on 8/2/23 by physical therapist (PT) #11. The visit note stated, “Patient does not have Bactrim [antibiotic] and wife is calling primary care physician.” A review of the referral documents revealed the patient was to take Bactrim 400-80 mg tablet every Monday, Wednesday, and Friday for 23 days with an end date of 8/11/23. There was no evidence that agency staff communicated with the physician regarding the Bactrim. An interview with PT #11 on 8/30/23 at 9:25 a.m. confirmed there was no documentation regarding the Bactrim after the initial assessment.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on observation, clinical record review, and staff interview the physical therapy assistant performed wound care without orders for 1 of 7 home visits (#9). Findings included: Patient #9 was admitted on 8/8/23 with a diagnosis of type 2 diabetes mellitus with diabetic polyneuropathy (damage or disease affecting peripheral nerves). The Plan of Care (POC) for 8/8/23-10/6/23 included orders for skilled nursing one time per week for four weeks; physical therapy weekly for four weeks; and speech therapy twice weekly for eight weeks. On 8/23/23, LPN #6 conducted a home visit. The visit note stated, “Patient has 3 very small scabbed areas to top of sacrum [bone at the base of the spine]…SN cleansed with NS [normal saline], applied barrier cream and foam bordered dressing for protection. MD sent communication.” A “Physician Communication” note for 8/23/23 stated, “Patient has 3 small scabbed areas to top of sacrum related to pressure. Acceptable to clean with NS, apply barrier cream and cover with foam bordered dressing?...” A visit note on 8/28/23 by LPN #6 stated, “Patient has 3 very small scabbed areas to top of sacrum…SN cleansed with NS, applied barrier cream and bordered dressing…MD sent communication last visit.” The physician signed the order on 8/30/23. A joint home visit was conducted with physical therapy assistant #7 on 8/29/23 at 8:00 a.m. During the visit the patient reported a wound on the sacrum. The physical therapy assistant applied a barrier ointment and a silicone foam dressing. There was no order for physician therapy assistant to apply dressing. During the visit, the clinical manager confirmed the PTA did not have orders to apply a dressing.

An onsite recertification survey was conducted 05/03/21 to 05/05/21. No deficiencies were identified to the Emergency Prepardeness Program. ABH

An onsite recertification survey was conducted 05/03/21 to 05/05/21. A Deficiency to the Medicare Conditions of Participation was identified. ABH

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 policy and procedure, observation, clinical record review, and staff and patient/caregiver interviews, the agency failed to review all current medications for 4 of 7 patients that received a home visit (#16,17, 11, and 15). Based on policy and procedure, observation, clinical record review, and staff and patient/caregiver interviews, the agency failed to review all current medications for 4 of 7 patients that received a home visit (#16,17, 11, and 15). Findings include: A policy titled "Administration and Documentation of Medications,3-004.1" was provided by the agency director on 05/05/21 at 2:08 p.m. revised 09/01/12 revealed, " ...as part of the assessment process, a drug history will be taken and comparison made between the physician's orders and the current medication the patient is taking ..." Patient #16 was admitted on 03/30/21 with diagnoses of hepatic failure (disease of the liver), other cirrhosis of liver, hypertensive heart disease (high blood pressure), type 2 diabetes, and unspecified heart failure. The Plan of Care (POC) for 03/30/21-05/28/21 included the following orders: skilled nursing 1 time a week for 1 week, 2 times a week for 2 weeks, and 1 time a week for 1 week; physical therapy 1 time a week for 1 week, 2 times a week for 4 weeks; and occupational therapy for 2 times a week for 2 weeks. A home visit was conducted via zoom on 05/04/21 at 8:30 a.m. with the registered nurse. A review of the current medications was conducted with the patient during the visit. The medication profile provided by the agency did not include the following medications: Tylenol 500mg (milligrams) ½ tablet daily as needed for pain, and brimonidine tartrate 0.2% 1 drop 2 times a day for glaucoma. The patient confirmed she has been using for the eye drops for about a year. An interview with Employee #2 on 5/5/21 at 3:10 p.m. confirmed these medications were not on the medication profile at the time of the visit on 05/04/21. Patient #17 was admitted on 04/04/21 with diagnoses of heart disease, alzheimer's disease, dementia, type 2 diabetes, and essential hypertension. The Plan of Care (POC) for 04/04/21 to 06/02/21 included the following orders: skilled nursing 2 times a week for 1 week, 2 times a week for 3 weeks; physical therapy 1 time a week for 1 week, 2 times a week for 3 weeks, and time a week for 1 week; and occupational therapy 1 time a week for 1 week, 2 times a week for 3 weeks. A home visit was conducted via zoom on 05/04/21 at 10:30 a.m. with the occupational therapist. A review of the current medications was conducted with the patient during the visit. The following discrepancy was identified during the home visit: The medication profile provided by the agency indicated the patient was taking aspirin 325mg (milligrams) oral tablet; take 1 tablet oral once a day for antiplatelet. The patient confirmed he was taking 81mg of aspirin daily. An interview with Employee #3 on 5/4/21 at 11:26 a.m. confirmed the correct dosage of the aspirin was not on the updated medication profile provided by the agency during the home visit 1. Patient #11 Patient #11 resides in an assisted living facility (ALF) and was admitted to the agency on 04/03/21 with a primary diagnosis of chronic obstructive pulmonary disease with acute lower respiratory infection. Plan of Care dated 04/03/21 to 06/01/21 revealed a medication order for "Oxygen 3L (liters)/min (minute) NC (nasal cannula) Continuously 3L aerosol; Inhale 3 liters per minute intranasally Continuous for breathing Start Date: 04/03/21." A virtual visit of Patient #11 conducted by the Speech Therapist, Employee #7, was observed on 05/04/21 at approximately 2:15 PM. During the virtual visit, Employee #7 verified the amount of oxygen that Patient 11 was using during the visit. After looking at the oxygen concentrator, Employee #7 stated, "You're on 2 liters ...the order is written for 3 liters. We'll have to call the doctor to clarify that." Review of the ALF medication administration record (MAR) printed 05/04/21 revealed the order "Check O2 (oxygen). 2L of continuous oxygen." An interview with the Clinical Manager, Employee #6 on 05/05/21 at approximately 3:00 PM, confirmed that Patient #11 was not receiving the amount of oxygen that was listed on the Plan of Care. Employee #6 stated that the physician was contacted to verify the correct amount of oxygen during the 05/04/21 visit and the agency was waiting to hear back from the physician for verification at the time of survey exit. 2. Patient #15 Patient #15 was admitted to the agency on 04/01/21 following right hip replacement surgery after a right hip fracture. Plan of Care dated 04/01/21 to 05/30/21 revealed orders for physical therapy 2 times per week for 4 weeks and occupational therapy 2 times per week for 4 weeks. A virtual visit of Patient #15 conducted by the Physical Therapist (PT), Employee #8, was observed on 05/04/21 at approximately 1:45 PM. During the virtual visit, Employee #8 reviewed Patient #15's medications and supplements in the home and compared them to the agency medication list. Employee #8 identified that Patient #15 was taking Calcium 500 milligrams daily, Vitamin B12 2.4 micrograms daily, Vitamin D3 5,000 IUs (international units) daily, Ferrous Sulfate (iron) 325 milligrams daily, and Lidocaine 2% OTC (over the counter) three times daily as needed for mouth sores, that were not on the agency medication list. Employee #8 was observed adding these medications to the agency medication list during the 05/04/21 virtual visit.