Asap Home Health Service

“Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to review and update their emergency preparedness plan at least every two years for seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). The deficient practice has the potential to affect the safety of the patients and put them at risk of danger during an emergency or disaster. A record review of Patient 1 medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnosis including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated 11/28/2023 – 1/26/2024, indicated start of care date 12/8/2021 with diagnosis including congenital tracheomalacia (weakness of the walls of the windpipe). A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 11/25/2023-1/23/2024, indicated a start of care date on 5/29/2023, with a primary diagnosis of cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 6’s medical record titled, “OASIS-E Transfer Discharge”, dated 11/30/2023, indicated a start of care date on 11/15/2023, with diagnosis including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 7’s medical record titled, “OASIS-E Transfer Discharge”, dated 8/22/2023, indicated a start of care date on 7/23/2023, with diagnosis including chronic respiratory failure (difficulty breathing). During a record review of HHA’s “Emergency Preparedness Program” binder, form titled “Acknowledgement of Emergency Operation Program Review” dated 4/5/2023, indicated sections “Reviewed and Approved: Administrator, on behalf of the Agency” were left blank. During a concurrent interview and record review on 1/25/2024, at 12 p.m., with the Administrator (ADM), ADM of HHA’s Emergency Preparedness Plan binder, ADM stated form “Acknowledgement of Emergency Operation Program Review” dated 4/5/2023, was not signed. ADM stated he will notify the person in charge. During a concurrent interview and record review on 1/26/2024, at 12 p.m. with the Business Manager (BM) of HHA’s Emergency Preparedness Plan binder, BM stated the binder was reviewed by herself and ADM, but both forgot to sign. BM stated their signatures would indicate the plan of action was approved with the most recent information. A review of the agency’s undated policy and procedure titled, “Emergency Management Plan” revised 4/2021 indicated “The Emergency Preparedness Program, Emergency Plan and Policies and Procedures will be reviewed and updated at least every 2 years, or more frequently if needed.” A review of HHA’s policy and procedure titled “Emergency Management Plan” revised 4/2021, indicated “The Emergency Preparedness Program, emergency Plan and Policies and Procedures will be reviewed and updated at least every 2 years, or more frequently if needed.””

“Update of the comprehensive assessment CFR(s): 484.55(d) Standard: Update of the comprehensive assessment. The comprehensive assessment must be updated and revised (including the administration of the OASIS) as frequently as the patient’s condition warrants due to a major decline or improvement in the patient’s health status, but not less frequently than- This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure two of seven sample patients’ (Patient 1 and Patient 4) plans of care (an individualized care planned) were updated to reflect their current medications. This failure had the potential to result in confusion to staff and caregivers, placing the patients at risk of a drug-to-drug interaction and harm by not knowing which medications the patients were taking. 1. A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). During a concurrent interview and record review on 1/25/2024, at 12:30 p.m., with Registered Nurse 1 (RN1) of Patient 1’s medical record form titled “Physician Order” dated 11/5/2023, indicated “New Medication – Quetiapine” and “Discontinued – Gabapentin”. RN1 stated the order was received on 11/5/2023 and he reviewed Patient 1’s POC on 11/16/2023. RN1 stated when there are changes to a patients POC, the HHA updates the POC, prints out a new one, and shreds the old POC. During a concurrent interview and record review on 1/25/2024 at 12:30 p.m., with Registered Nurse 1 (RN1) of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, form indicated Gabapentin (seizure Medication), RN1 stated Gabapentin was discontinued and it should not be documented on Patient 1’s POC. RN1 stated there was a doctor’s order to give Patient 1 Quetiapine (medication for depression), but it was not documented on Patient 1’s POC. 2. A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). During a concurrent interview and record review on 1/25/2024, at 10:43 a.m., RN 1 reviewed Patient 4’s record titled, “Home Health Certification and Plan of Care” (POC), for certification period 12/4/2023 -2/1/2023. RN 1 stated he was the one who reviewed the POC to make sure there were no medication errors and to make sure everything provided was accurate. RN 1 stated he reviewed the POC for accuracy on 11/6/2023. During an observation during the home visit on 1/24/2024, at 8:45 a.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Patient 4’s home medications. The medication Clobazam (to prevent convulsions-involuntary body movements caused by the brain) 20 mg (mg-milligram, unit of measurement) label indicated to take ½ (half) tablet by mouth every morning and 1 tablet every evening. There were two bottles of medication Risperidone (to threat psychotic (mental disorder) episodes). One bottle had a label to take 0.5 mg tablet by mouth every morning. The second medication bottle label indicated to take 1 mg by mouth every evening. Medication Vitamin D3 (a supplement) 125 mcg (mcg-micrograms) was also at the home. A review of Patient 4’s record titled, “Home Health Certification and Plan of Care” (POC), for certification period 12/4/2023 -2/1/2023, did not accurately list the medications Patient 4 was taking at home. The HHA failed to ensure the plan of care was updated to accurately reflect the medications Patient 4 was taking at home. A review of HHA’s policy and procedure titled “Plan of Treatment” undated, indicated “A home health agency has established policies and procedures for assuring that services and times to be provided are specified under a plan of treatment established and regularly reviewed by the physician responsible for the care of each patient and singed within 20 days. The health professional is expected to bring to the attention of the physician, those changes in the patient’s condition which indicate the need for altering the treatment plan or for termination services.””

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview the Registered Nurse Supervisor (RN1) failed to change gloves while providing care to two of seven sample patients (Patient 1 and Patient 2). This failure had the potential to result in placing patients at risk of contracting and/or transmitting diseases to other patients. A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnosis including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). During a joint home visit on 1/24/2024 at 12 p.m., with RN1 to Patient 1’s and Patient 2’s home, RN1 noted using hand sanitizer prior to providing care to Patient 1. RN1 noted started providing care to Patient 2 without removing the gloves he was wearing while providing care to Patient 2. RN1 noted taking off and using hand sanitizer after providing care to both Patient 1 and Patient 2. During an interview on 1/25/2024 at 9:30 a.m., with RN1, RN1 stated he should have changed the gloves he was wearing when providing care to different patients. RN1 stated, “I am assuming since you’re asking, that I should have.” RN1 stated he should have changed gloves between patients to prevent transmitting a disease that could be occurring. A review of HHA’s policy and procedure titled “Infection Control for Nursing Services” undated, indicated “Proper hand washing technique will be done before and after patient contact.” A review of HHA’s policy and procedure titled “Hand Washing Technique” undated, indicated “Hands must be washed before and after of patient contact with an antimicrobial soap.””

“Competency evaluation CFR(s): 484.80(c)(1)(2)(3) Standard: Competency evaluation. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section. (1) The competency evaluation must address each of the subjects listed in paragraph (b)(3) of this section. Subject areas specified under paragraphs (b)(3)(i), (iii), (ix), (x), and (xi) of this section must be evaluated by observing an aide’s performance of the task with a patient or pseudo-patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient, or with a pseudo-patient as part of a simulation. (2) A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section. (3) The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure competency evaluation must be performed by a registered nurse in consultation with other skilled professionals providing services for two of the seven (Patient 4 and Patient 5) sampled patients care staff, prior to working independently. This deficient practice had the potential to result in health status decline for the patients by not ensuring the staff were competent to provide care. 1. A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). During a concurrent observation, interview, and record review during the home visit on 1/24/2024, at 8:45 a.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Patient 4’s home medications using record titled, “Medication Profile”, dated 12/22/2023. The following medications were not updated in Patient 4’s “Medication Profile”: “Clobazam” (to prevent convulsions-involuntary body movements caused by the brain) 20 mg (mg-milligram, unit of measurement) take ½ (half) tablet by mouth every morning and 1 tablet every evening. The medication profile indicated a 10 mg tablet to be taken twice a day. LVN 2 stated the medication profile did not indicate the dosage and instructions according to the label. The label and the medication profile did not match. LVN 2 stated it was important for the instructions on the label match the medication profile so there are no medication errors. LVN 2 stated it was the responsibility of the Registered Nurse (RN) to update the medication profile. LVN 2 stated, “I just report if there is a change”. “Risperidone” (to threat psychotic (mental disorder) episodes). There were two bottles of the medication. One bottle had a label to take 0.5 mg tablet by mouth every morning. The second bottles were to take 1 mg by mouth every evening. LVN 2 stated the medication profile did not indicate the 0.5 mg dose and the instructions on how to take the medication were not correct in the medication profile. “Vitamin D3” (a supplement) 125 mcg (mcg-micrograms). LVN 2 stated the vitamin was not listed in the medication profile. Vitamin D as listed, patient 4 was no longer taking. During an interview on 1/24/2024 at 12:50 p.m., Registered Nurse 1 (RN1), stated patients’ medication should be reconciliated every time there is a skilled nurse visit to make sure there is no changed in medications or patient condition. RN1 stated if medication reconciliation is not done, “we might not be aware of any changes with patients”. During a concurrent interview and record review on 1/25/2024, at 1:05 p.m., the Administrator (ADM) reviewed LVN 2’s employee file records titled, “Skills Inventory RN/LV Only”, dated 5/9/2027, and “Test of General Knowledge-(RN/LVN) Skilled Nurse”, dated 5/9/2017. The ADM stated there was no initial competency evaluation for LVN 2, the only thing done was a knowledge exam. The ADM stated the exam mostly tested for medication knowledge and LVN 2 had not passed the exam. The ADM stated it was the responsibility of the Registered Nurse Supervisor or the Director of Patient Care services to ensure skill and knowledge competency were done. Ensuring staff are competent and knowledgeable were important because if not done, patients can be put in danger by not ensuring the staff were proficient with their skills. 2. A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 11/25/2023-1/23/2024, indicated a start of care date on 5/29/2023, with a primary diagnosis of cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). During a concurrent interview and record review on 1/25/2024, at 12:45 p.m., the ADM reviewed Certified Home Health Aide and Patient 5’s caregiver (CHHA/CG 3) employee file. The ADM stated CHHA/CG 3 did not have a competency evaluation. The ADM stated an observation of the CHHA/CG 3’s skills should have also occurred, and this too was not done. The ADM stated it was important to check the CHHA/CG 3’s skill for the safety of the patient. To make sure CHHA/CG 3 was proficient in his scope of practice. A review of HHA’s policy and procedure titled “Assessing Competency for Clinical Staff” undated, indicated “The clinical staff shall take be evaluated with an ongoing demonstration checklist of skills at their scope of practice. The clinical staff shall be assessment annually for ongoing evaluation of competency.””

“12 hours inservice every 12 months CFR(s): 484.80(d) Standard: In-service training. A home health aide must receive at least l2 hours of in-service training during each 12-month period. In-service training may occur while an aide is furnishing care to a patient. This Standard is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure two of seven sample patients (Patient 1 and Patient 2) provided Certified Home Health Aide (CHHA) services completed the 12 hours in services every 12 months as required. This failure had the potential to result in placing the patients being taken care of CHHAs at risk of being taken care of improperly which may cause harm or damage that may lead to hospitalization. A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnoses including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). During a joint home visit on 1/24/2024 at 12 p.m., with CHHA/Care Giver 1 (CHHA/CG1) to Patient 1 and Patient 2’s home, CHHA/CG1 stated she has not attended any in services in the last six months. CHHA/CG1 stated she was Patient 1’s and Patient 2’s CHHA and care giver. During a concurrent interview and record review on 1/25/2024 at 11:46 a.m., with the Administrator (ADM) of CHHAs in service binder, ADM stated there were no documented in services for CHHA/CG1 for the year 2023. ADM stated they were using an electronic system to assign CHHA classes/in services. The HHA generated the assign course, then generated an in-house certificate with their letterhead. ADM stated that they sent their generated certificates to their CHHA to sign. ADM stated CHHA need to be in serviced to ensure that they’re in line with the plan of care and that they stay proficient. Also, to keep the lines of communication open between the HHA and their CHHA. A review of HHA’s policy and procedure titled “In Services Education” undated, indicated “In-services will be presented each month to develop and enhanced skills, broaden knowledge specific to home health. At least 12 hours annually provided for CHHA’s”.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on interview and record review the HHA failed to ensure four of seven sampled patients (Patient 1, Patient 2, Patient 3, and Patient 4) entries in the clinical records must be signed by the primary author who reviewed and approved the entries. This failure resulted in an incomplete medical record. 1. A record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 1 medical record form titled “Hours Worked: Horas Trabajadas:” dated 1/14/2024 to 1/20/2024, indicated section “Aides name” had CHHA/CG1’s name printed on form. It also indicated form was not signed by CHHA/CG1. 2. A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnosis including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 2 medical record form titled “Hours Worked: Horas Trabajadas:” dated 1/14/2024 to 1/20/2024, indicated section “Aides name” had CHHA/CG1’s name printed on form. It also indicated form was not signed by CHHA/CG1. 3. A review of Patient 3 medical record form titled “Home Health Certification and Plan of Care” dated 11/28/2023 – 1/26/2024, indicated start of care date 12/8/2021 with diagnoses including congenital tracheomalacia (weakness of the walls of the windpipe). A review of Patient 3 medical record form titled “Hours Worked: Horas Trabajadas:” dated 1/14/2024 to 1/20/2024, indicated section “Aides name” had CHHA/CG2’s name printed on form. It also indicated form was not signed by CHHA/CG2. During a concurrent interview and record review on 1/25/2024 at 10:22 a.m., with the Administrator (ADM) of Patient 1, Patient 2, and Patient 3’s CHHA visit notes, ADM stated he knows which discipline wrote the patient visit notes because they send their notes to the HHA via their personal email. ADM stated that the HHA makes sure the patients visit notes are coming from the visiting nurses’ emails and that they also look at their patterns. ADM stated, “we authenticate the note because we know who sent it and where it’s coming from.” ADM stated the CHHA notes are not authenticated, on their own. 4. A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). During a concurrent interview and record review on 1/23/2024, at 12:20 p.m., Licensed Vocational Nurse 1 (LVN 1), reviewed Patient 4’s record titled, “Skilled Nursing Visit Note”, dated 1/13/2024. The record indicated a typed or electronic entry with Licensed Vocational Nurse 2 (LVN 2)’s name and initials. There was no signature. LVN 1 stated the document did not have the nurse’s signature. During an interview on 1/24/2024, at 8:55 a.m., LVN 2 stated he typed in his initials and name into nursing notes but this was not considered his signature. LVN 2 stated, “yes, I think the notes should have my signature, but the capability was not provided by the agency”. LVN 2 stated the importance of including a signature in the notes is to be held responsible for what is documented. To show the documentation was done by him, to show he was the author of the note.”

“Protection of records CFR(s): 484.110(d) Standard: Protection of records. The clinical record, its contents, and the information contained therein must be safeguarded against loss or unauthorized use. The HHA must be in compliance with the rules regarding protected health information set out at 45 CFR parts 160 and 164. This Standard is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure patients’ clinical records are protected/safeguarded against unauthorized use for seven of seven sampled patients (Patient 1, Patient 2, Patient 3, and Patient 4, Patient 5, Patient 6, and Patient 7) by failing to: -Ensure Certified Home Health Aides (CHHA) and Licensed Vocational Nurses (LVN) were restricted to store confidential patients’ visit notes and other sensitive patients’ information in their personal cell phone, laptop and/or tablet. This failure had the potential to result in patients personal and confidential information being accessed by unknown individual/s. 1. A record review of Patient 1 medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnoses including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). Form also indicated it had the HHA’s Electronic System (ES) title/name printed on the left bottom of the forms. A review of Patient 1 medical record form titled “Hours Worked: Horas Trabajadas:” dated 1/14/2024 to 1/20/2024, indicated section “Aides name” had CHHA/CG1’s name printed on form. It also indicated form was not signed by CHHA/CG1. A review of Patient 1’s medical record from titled “OASIS-E Recertification” dated 12/7/2023, indicated it had the HHA’s Electronic System (ES) title/name printed on the left bottom of the forms. 2. A review of Patient 2 medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnoses including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). Form also indicated it had the HHA’s Electronic System (ES) title/name printed on the left bottom of the forms. A review of Patient 2 medical record form titled “Hours Worked: Horas Trabajadas:” dated 1/14/2024 to 1/20/2024, indicated section “Aides name” had CHHA/CG1’s name printed on form. It also indicated form was not signed by CHHA/CG1. A review of Patient 2’s medical record from titled “OASIS-E Recertification” dated 12/7/2023, indicated it had the HHA’s Electronic System (ES) title/name printed on the left bottom of the forms. 3. A review of Patient 3 medical record form titled “Home Health Certification and Plan of Care” dated 11/28/2023 – 1/26/2024, indicated start of care date 12/8/2021 with diagnoses including congenital tracheomalacia (weakness of the walls of the windpipe). Form also indicated it had the HHA’s Electronic System (ES) title/name printed on the left bottom of the forms. A review of Patient 3 medical record form titled “Hours Worked: Horas Trabajadas:” dated 1/14/2024 to 1/20/2024, indicated section “Aides name” had CHHA/CG2’s name printed on form. It also indicated form was not signed by CHHA/CG2. A review of Patient 3’s medical record from titled “OASIS-E Recertification” dated 11/4/2023, indicated it had the HHA’s Electronic System (ES) title/name printed on the left bottom of the forms. 4. A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). During an interview on 1/24/2024, at 8:55 a.m., Licensed Vocational Nurse 2 (LVN 2) stated the HHA provided an electronic template to him, via electronic mail to document his visit notes. LVN 2 stated he did not need to log in to access the form. Once the nursing visit was completed, LVN 2 would email the note from his personal email address to the HHA email. During an interview on 1/25/2024, at 10:00 a.m., the ADM stated clinical records in employee’s personal cell phone and/or personal computer device were safeguarded because their devices required a password to access their device. 5. A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 11/25/2023-1/23/2024, indicated a start of care date on 5/29/2023, with a primary diagnosis of cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 5’s medical record from titled “OASIS-E Recertification” dated 11/15/2023, indicated “Electronically Signed…” 6. A review of Patient 6’s medical record titled, “OASIS-E Transfer Discharge”, dated 11/30/2023, indicated a start of care date on 11/15/2023, with diagnoses including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). Further review of the record indicated, “Electronically Signed…” 7. A review of Patient 7’s medical record titled, “OASIS-E Transfer Discharge”, dated 8/22/2023, indicated a start of care date on 7/23/2023, with diagnoses including chronic respiratory failure (difficulty breathing). Further review of the record indicated, “Electronically Signed…” During an interview on 1/23/2024 at 10:33 a.m., with Medical Record (MR), MR stated the HHA has an Electronic Medical Record (EMR) system, but that the system does not print out a census. During an interview on 1/23/2024 at 10:40 a.m., with Registered Nurse 1 (RN1), RN1 was made aware of needed current patient census document from their EMR. RN1 stated “let me see what I can do.” During an interview on 1/23/2024 at 10:50 a.m., with the Administrator (ADM), ADM stated the HHA does not have an EMR, therefore patients have hard files. ADM stated when a nurse completes a physical assessment, she/he enters the information into their HHA electronic system (ES) and from there patients’ initial assessments, ongoing assessments, plan of care, and communication notes are generated. During a concurrent interview and record review on 1/23/2024at 11:05 a.m., with RN1 of HHA patient census form titled “Census by Date Range” dated 1/1/2024-1/23/2024, RN1 provided and stated census form was generated from their EMR system. During an interview on 1/23/2024 at 12:21 p.m., with License Vocational Nurse 1 (LVN1), LVN1 stated Certified Home Health Aides (CHHA) document patient visit notes in a template on their personal cell phone, laptop, or tablet. LVN1 stated once a CHHA fills out the template, they send it to the HHA via email. During an observation and interview on 1/24/2024 at 12:30 p.m., with Certified Home Health Aide/Care Giver 1 (CHHA/CG1), CHHA/CG 1 noted using a tablet to demonstrate where she documents Patient 1 and Patient 2’s visit. CHHA/CG 1 stated she documents her assessment in her tablet daily using a drop box. CHHA/CG1 stated the HHA receives the documentation instantly. During an interview on 1/24/2024 at 12:50 pm., with RN1, RN 1 stated CHHAs have a PDF form in the drop box that they document their visit notes. RN1 stated a drop box is an online forum. RN1 stated, “We create a patient profile in the drop box, then access is given to different people to document on or attach their assessment notes. Once they document on the form, we print it out and place it in the patient’s file.” RN1 stated that if the form is in a PDF format, the CHHAs can put in their electronic signature. A review of HHA’s policy and procedure titled “Workstation Use and Security – When using AXXESS” undated, indicated “Workforce members will be instructed not to share passwords with others, except to assure business continuity. (HHA) will implement additional precautions for portable workstations that store ePHI. Workforce members will not store ePHI on unencrypted workstations.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) received information regarding the State toll free home health telephone hotline, its contact information, its hours of operation, and its purpose. This failure resulted in a violation of patient’s rights due to not having the information necessary to make a complaint regarding the agency’s care. A record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnosis including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated 11/28/2023 – 1/26/2024, indicated start of care date 12/8/2021 with diagnosis including congenital tracheomalacia (weakness of the walls of the windpipe). A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 11/25/2023-1/23/2024, indicated a start of care date on 5/29/2023, with a primary diagnosis of cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 6’s medical record titled, “OASIS-E Transfer Discharge”, dated 11/30/2023, indicated a start of care date on 11/15/2023, with diagnoses including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 7’s medical record titled, “OASIS-E Transfer Discharge”, dated 8/22/2023, indicated a start of care date on 7/23/2023, with diagnoses including chronic respiratory failure (difficulty breathing). A review of HHA’s patient admission folder indicated the State home health contact information, hours of operation, and purpose were not included in their forms. A review of HHA’s form titled “Patient Rights and Responsibilities” undated, indicated the State home health contact information, hours of operation, and purpose were not included in their forms. During a concurrent interview and record review on 1/25/2024, at 9:40 a.m., with Registered Nurse 1 (RN1) of patients’ admission folder, RN1 stated he was unable to locate the State complaint hotline number or contact information in the documents inside the folder. During a concurrent interview and record review on 1/25/2024 at 9:50 a.m., with the Administrator (ADM) of patients’ admission folder, ADM stated the State complaint information was not included in the patient’s packet. ADM stated it should be included because it’s part of their right to have that information in case they need to 4er354call and make a complaint. A review of HHA’s policy and procedure titled “Patient Bill of Rights” undated, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights. The Patient Bill of Rights statement defines the right of the patient to: Receive in writing, prior to the start of care, the telephone numbers for the State Home Health Hotline and the Administration number, including hours of operation, and the purpose of the hotlines to receive complaints or questions about the organization.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on interview and record review the Home Health Agency (HHA) failed to ensure seven of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7) received information on Federal and State funded entities available in the areas they reside in. This failure had the potential to prevent patients to be familiar with the services that are available to them. A record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnoses including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnoses including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated 11/28/2023 – 1/26/2024, indicated start of care date 12/8/2021 with diagnoses including congenital tracheomalacia (weakness of the walls of the windpipe). A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 11/25/2023-1/23/2024, indicated a start of care date on 5/29/2023, with a primary diagnosis of cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 6’s medical record titled, “OASIS-E Transfer Discharge”, dated 11/30/2023, indicated a start of care date on 11/15/2023, with diagnoses including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 7’s medical record titled, “OASIS-E Transfer Discharge”, dated 8/22/2023, indicated a start of care date on 7/23/2023, with diagnoses including chronic respiratory failure (difficulty breathing). A review of HHA’s patient admission folder indicated the State and Federally funded entities contact information were not included in their forms. During a concurrent interview and record review on 1/25/2024 at 9:53 a.m., with the Administrator (ADM) of patients’ admission folder, ADM stated the folder did not contain the State and Federally funded entity contact information. ADM stated the HHA needed to provide patients with the information, so they can be informed of the available resources. A review of HHA’s policy and procedure titled “Patient Bill of Rights” undated, indicated “The patient will be informed verbally and in writing during the initial evaluation visit, in advance of furnishing care of their rights. The Patient Bill of Rights statement defines the right of the patient to: The names, addresses and telephone numbers of the following Federally funded and State-funded entities that serve the area where the patient resides: Agency of aging; center for independent living; Aging and disability resource center; Quality improvements organizations.””

“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) failed to review and document all the current medications and treatments for two of seven sampled patients (Patient 2 and Patient 4) were currently using. This deficient practice placed the patients at risk of drug-to-drug interaction and harm by not knowing which medications the patients were taking. 1. A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnoses including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 2’s medical record form titled “Physician Order” dated 3/16/2023, indicated “Neomycin-Polymyxin B- Dexamethasone” one drop into each eye two times daily. A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated “Neomycin-Polymyxin B- Dexamethasone” one drop into each eye two times daily. A review of Patient 2’s medical record form provided on 1/23/2024, titled “Medication Profile” dated 10/17/2023 to 12/15/2023, indicated Patient 2 was ordered “Neomycin-Polymyxin B- Dexamethasone” one drop into each eye two times daily. During a joint home visit on 1/24/2024, at 10 a.m., with Registered Nurse 1 (RN1) and Certified Home Health Aide/Care Giver 1 (CHHA/CG1) at Patient 2’s home, RN1 reviewed Patient 2’s home medication. Patient 2’s medication bottle of Neomycin-Polymyxin B- Dexamethasone eye drop label read the following: one drop into each eye three times daily. Label also indicated prescription was filled on 7/5/2023. CHHA/CG1 stated she instills Patient 2’s eye drops as needed. The HHA failed to ensure Patient 2’s medication profile was updated to reflect the current eye drop medication frequency. 2. A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). During the home visit on 1/24/2024, at 8:45 a.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Patient 4’s home medications using record titled, “Medication Profile”, dated 12/22/2023. The following medications were not updated in Patient 4’s Medication Profile: -Clobazam (to prevent convulsions-involuntary body movements caused by the brain) 20 mg (mg-milligram, unit of measurement) take ½ (half) tablet by mouth every morning and 1 tablet every evening. The medication profile indicated a 10 mg tablet to be taken twice a day. LVN 2 stated the medication profile did not indicate the dosage and instructions according to the label. The label and the medication profile did not match. LVN 2 stated it was important for the instructions on the label match the medication profile so there are no medication errors. LVN 2 stated it was the responsibility of the Registered Nurse (RN) to update the medication profile. LVN 2 stated, “I just report if there is a change”. -Risperidone (to threat psychotic (mental disorder) episodes). There were two bottles of the medication. One bottle had a label to take 0.5 mg tablet by mouth every morning. The second bottles were to take 1 mg by mouth every evening. LVN 2 stated the medication profile did not indicate the 0.5 mg dose and the instructions on how to take the medication were not correct in the medication profile. -Vitamin D3 (a supplement) 125 mcg (mcg-micrograms). LVN 2 stated the vitamin was not listed in the medication profile. Vitamin D as listed, Patient 4 was no longer taking. The HHA failed to ensure Patient 4’s medication profile accurately reflected the medications he was taking. During an interview on 1/24/2024 at 12:50 p.m., with Registered Nurse 1 (RN1), RN1 stated patients’ medication should be reconciliated every skilled nurse visit to make sure there were no changes their medications or patient condition. RN1 stated if medication reconciliation was not done, “We might not be aware of any changes with patients”. A review of HHA’s policy and procedure titled “Administering Medication & Profile” undated, indicated “The RN (Registered Nurse) will be responsible for monitoring the patient’s medication regimen through a collaborative effort with the multi-disciplinary team and physician involved in the patients care. An accurate and current list of all prescription and over the counted medication taken by the patient will be maintained on the medication profile. Changes in the medication n regimen will be documented in the clinical record…””

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on interview and record review, the Home Health Agency (HHA) failed to ensure a Registered Nurse updated the comprehensive assessment for the recertification period for five of seven sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). This deficient practice had the potential to result in the inability to identify the decline or progress of the patient’s health status to promptly implement further intervention and treatment in coordination the physician. 1. A record review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 1’s medical record form titled “OASIS- E Recertification” dated 12/7/2023, indicated Patient 1 had a recertification assessment on 12/7/2023. During an interview on 1/25/2024 at 12:30 p.m., with Registered Nurse 1 (RN1), RN1 stated Patient 1’s last recertification assessment was conducted on 12/7/2023, and Patient 1’s current recertification period began on 12/16/2023. RN1 stated Patient 1’s recertification assessment was conducted nine days before his recertification period to be able to generate Patient 1’s plan of care. The HHA failed to ensure Patient 1’s recertification assessment was performed five days prior the ending of his last recertification period. 2. A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnosis including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). A review of Patient 2’s medical record form titled “OASIS- E Recertification” dated 12/7/2023, indicated Patient 2 had a recertification assessment on 12/7/2023. During an interview on 1/25/2024 at 1:40 p.m., with RN1, RN1 stated Patient 2’s last recertification assessment was conducted on 12/7/2023, and Patient 2’s current recertification period began on 12/16/2023. RN1 stated Patient 2’s recertification assessment was conducted nine days before her recertification period to be able to generate Patient 2’s plan of care. The HHA failed to ensure Patient 2’s recertification assessment was performed five days prior the ending of her last recertification period. 3. A review of Patient 3’s medical record form titled “Home Health Certification and Plan of Care” dated 11/28/2023 – 1/26/2024, indicated start of care date 12/8/2021 with diagnosis including congenital tracheomalacia (weakness of the walls of the windpipe). A review of Patient 3’s medical record form titled “OASIS- E Recertification” dated 11/4/2023, indicated Patient 3 had a recertification assessment on 11/4/2023. During an interview on 1/25/2024 at 12:20 p.m., with RN1, RN1 stated Patient 3’s last recertification assessment was conducted on 11/4/2023, and Patient 3’s current recertification period began on 11/28/2023. RN1 stated Patient 3’s recertification assessment was conducted 24 days before her recertification period to be able to generate Patient 3’s plan of care. The HHA failed to ensure Patient 3’s recertification assessment was performed five days prior the ending of her last recertification period. 4. A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). During a concurrent interview and record review on 1/25/2024, at 10:48 a.m., RN 1 reviewed Patient 4’s record titled, “OASIS-E Recertification”, dated 11/14/2023. RN 1 stated this was the recertification assessment for the next home health period to start on 12/4/2023. RN 1 stated the assessment was done ahead of time because it was needed to make the plan of care, that way the doctor can review and sign the plan of care. The HHA failed to ensure Patient 4’s recertification assessment was performed five days prior the ending of her last recertification period. 5. A review of Patient 5’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 11/25/2023-1/23/2024, indicated a start of care date on 5/29/2023, with a primary diagnosis of cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). During a concurrent interview and record review on 1/25/2024, at 11:15 a.m., RN 1 reviewed Patient 5’s record titled, “OASIS-E Recertification”, dated 11/15/2023. RN 1 stated this was the recertification assessment for the next home health period to start on 11/25/2023. RN 1 stated the assessment was done ahead of time because it was needed to make the plan of care, that way the doctor can review and sign the plan of care. The HHA failed to ensure Patient 5’s recertification assessment was performed five days prior the ending of her last recertification period. A review of HHA’s policy and procedure titled “Reassessment/Recertification” undated, indicated “For each new episode of care Medicare adults, a comprehensive assessment will be completed no earlier that five (5) days before and no later than one (1) day before the calendar day on which the new episode of care will begin for Medicare adults. For each new episode of care, Non-Medicare or Pediatrics, a comprehensive assessment will be completed within 30 days before and no later that 1 (one) day before the calendar day on which the new episode of care will begin.””

“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, interview, and record review the Home Health Agency (HHA) failed to ensure two of seven sample patients (Patient 1 and Patient 2) received treatments and/or services in accordance with their written plans of care by not monitoring Patient 1‘s weight and not reassessing Patients 2’s blood pressure (BP). This failure had the potential to result in placing the patients at risk of unintentional weight loss or gain and out of control BP results. 1. A review of Patient 1’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 2/2/2010 with diagnosis including autistic disorder (a neurological and developmental disorder that affects interactions with others, communication, learning, and behavior). A review of Patient 1’s medical record form titled “HHA Care Plan” dated 12/7/2023, indicated “Weight – Every Week”. A review of Patient 1’s medical record form titled “Hours Worked: Horas Trabajadas:” dated 1/14/2024 to 1/20/2024, indicated section “LBS/Pounds/Libras” were left blank for dated 1/14/2024 to 1/20/2024. During a concurrent interview and record review on 1/25/2024 at 1 p.m., with Registered Nurse 1 (RN1) of Patient 1’s medical record form titled “HHA Care Plan” dated 12/7/2023, RN1 stated the form indicated the CHHA’s (Certified Home Health Aide) home plan for the patient. RN1 stated Patient 1’s HHA Care Plan stated he should be weighed weekly. The HHA failed to ensure Patient 1’s weight was monitored on a weekly basis as ordered. 2. A review of Patient 2’s medical record form titled “Home Health Certification and Plan of Care” dated 12/16/2023 – 2/13/2024, indicated start of care date 12/3/2014 with diagnosis including cerebral palsy (impaired muscle coordination caused by damage to the brain before or at birth). It also indicated “Notify MD of diastolic BP greater that (>) 90… - If vital signs are out of the patients’ normal range, please try the following interventions and re-take. Vital signs: reposition the patient, check the equipment to endure its functionality, rotate the site, and redo the procedure.” During a joint home visit on 1/24/2024 at 12:30 p.m., with RN1 at Patient 2’s home, RN1 measured Patient 2’s blood pressure result of 122/103. RN1 continued to assess Patient 2 but was not observed reassessing Patient 2’s high diastolic (heart disease and stroke risk) pressure. During a concurrent interview and record review on 1/25/2024 at 9:30 a.m., with RN1 of Patient 2’s medical record, RN1 stated he forgot to check Patient 2’s blood pressure documented blood pressure parameters. RN1 stated he should have rechecked Patient 2’s blood pressure. The HHA failed to ensure Patient 2’s blood pressure was reassessed as indicated in her plan of care. A review of HHA’s policy and procedure titled “Plan of Treatment” undated, indicated “A home health agency has established policies and procedures for assuring that services and times to be provided are specified under a plan of treatment established and regularly reviewed by the physician responsible for the care of each patient and singed within 20 days. The health professional is expected to bring to the attention of the physician, those changes in the patient’s condition which indicate the need for altering the treatment plan or for termination services.””

“Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This Element is not met as evidenced by: Based on observation, interview, and record review the registered nurse failed to perform supervisory visits for License Vocational Nurse (LVN) services for one of seven sampled patients (Patient 4) provided LVN services. This deficient practice resulted in the LVN not be evaluated for patient care and services. A review of Patient 4’s medical record titled, “Home Health Certification and Plan of Care”, for certification period 12/4/2023 -2/1/2023, indicated a start of care date on 5/9/207, with a primary diagnosis of epilepsy (seizures). During a concurrent observation, interview, and record review during the home visit on 1/24/2024, at 8:45 a.m., Licensed Vocational Nurse 2 (LVN 2) reviewed Patient 4’s home medications using record titled, “Medication Profile”, dated 12/22/2023. The following medications were not updated in Patient 4’s “Medication Profile”: “Clobazam” (to prevent convulsions-involuntary body movements caused by the brain) 20 mg (mg-milligram, unit of measurement) take ½ (half) tablet by mouth every morning and 1 tablet every evening. The medication profile indicated a 10 mg tablet to be taken twice a day. LVN 2 stated the medication profile did not indicate the dosage and instructions according to the label. The label and the medication profile did not match. LVN 2 stated it was important for the instructions on the label match the medication profile so there are no medication errors. LVN 2 stated it was the responsibility of the Registered Nurse (RN) to update the medication profile. LVN 2 stated, “I just report if there is a change”. “Risperidone” (to threat psychotic (mental disorder) episodes). There were two bottles of the medication. One bottle had a label to take 0.5 mg tablet by mouth every morning. The second bottles were to take 1 mg by mouth every evening. LVN 2 stated the medication profile did not indicate the 0.5 mg dose and the instructions on how to take the medication were not correct in the medication profile. “Vitamin D3” (a supplement) 125 mcg (mcg-micrograms). LVN 2 stated the vitamin was not listed in the medication profile. Vitamin D as listed, patient 4 was no longer taking. During an interview on 1/24/2024 at 12:50 p.m., Registered Nurse 1 (RN1), stated patients’ medication should be reconciliated every time there is a skilled nurse visit to make sure there is no changed in medications or patient condition. RN1 stated if medication reconciliation is not done, “we might not be aware of any changes with patients”. During an interview on 1/25/2024, at 10:52 a.m., RN 1 stated the last time LVN 2 was supervised was on 12/22/2023. RN 1 stated LVN’s were supervised every month. RN 1 stated supervisory visits were important to make the sure LVN was following the plan of care and get updates for any changes. A record review of Patient 4’s record titled, “LVN Supervisory Visit”, dated 12/22/2023, indicated a supervisory visit was done however, the document did not specify if it was LVN 2 being supervised. The HHA failed to ensure LVN 2 was supervised every 30 days to make sure LVN 2 was reviewing the medication and updating the Medication Profile to ensure the HHA was aware of all the current medications Patient 4 was taking.”