Eagle Home Health

“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) failed to meet the Condition of Participation for Comprehensive Assessment of Patients as follows: 1. The HHA failed to assess the continuing need for home care services for five of 7 sampled patients (Patient 1, Patient 2, Patient 3, Patient 5 and Patient 6). (Refer to G532) 2. The HHA staff failed to review and document all medications changes and update the medication profile with currently used medications for one of 7 sampled patients (Patient 6). (Refer to G536) The cumulative effect of these systemic practices resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment.”

“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 for Care planning, coordination, quality of care as follows: 1. The Registered Nurse 1 (RN 1) failed to notify the physician regarding the elevated blood sugar levels for one of 7 sampled patients (Patient 1). Patient 1 who was diabetic (abnormal blood sugar levels) and was on insulin medication (medicine for diabetes). (Refer to G590) 2. The HHA failed to ensure diabetic management education was provided to one of 7 sample patients’ (Patient 1) Family Member 1 (FM 1). (Refer to G610) The cumulative effect of these systemic practices resulted in the home health agency’s inability to ensure the provision of quality health care in a safe environment.”

“Written notice of patient’s rights CFR(s): 484.50(a)(1)(i) (i) Written notice of the patient’s rights and responsibilities under this rule, and the HHA’s transfer and discharge policies as set forth in paragraph (d) of this section. Written notice must be understandable to persons who have limited English proficiency and accessible to individuals with disabilities; This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to provide a written advance directive (a written statement of a person’s wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) notice in a language easily understood, for one of 7 sampled patients (Patient 5). This failure resulted in a violation of patient’s rights due to patient and representative not understanding their rights and responsibilities in expressing health care preferences while under the HHA’s care. Findings: During a review of Patient 5’s Patient Information sheet, the Patient information sheet indicated a start of care date of 2/7/2024. During a review of Patient 5’s Home Health Certification (HHC) and Plan of Care (POC) form for certification period 4/7/2024 to 6/5/2024, the HHC and POC indicated patient’s diagnoses included hypertensive heart disease (heart problem that occur because of high blood pressure present over a long time), and chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). The HHA and POC indicated an order for the skilled nurse (SN) to visit the patient two times a week for 2weeks, and then once a week for 7 weeks for comprehensive skilled nursing assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services), observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks. During a joint home visit on 5/30/2024 at 10:25 a.m., at Patient 5’s residence with the Registered Nurse 2 (RN 2), Patient 5 was observed awake, alert, oriented x3 (to person, place, and time), and ambulatory using a walker. During an observation, on 5/30/2024 at 10:42 a.m., of the HHA folder at Patient 5’s residence revealed all the forms inside the agency folder that included the patient’s written Bill of Rights was in English. During an interview on 5/30/2024 at10:45 a.m. with Patient 5, Patient 5 stated his preferred language for speaking and reading was Farsi (language in Iran [country in middle east]). During an interview, on 5/31/2024, at 12:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated it was important for the contents in the HHA folder to be in patient’s preferred language, so Patient 5 will understand the information in a manner he could understand. During a review of HHA’s undated policy and procedure (P&P) titled, “Patients’ Bill of Rights/Responsibilities,” the P&P indicated the Patient Bill of Rights/Responsibilities should be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services in a language and manner he/she can reasonably be expected to understand.”

“Continuing need for home care CFR(s): 484.55(c)(3) The patient’s continuing need for home care; This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to assess the continuing need for home care services for five of 7 sampled patients (Patients 1, 2, 3, 5, and 6). This deficient practice resulted in the provision of the unnecessary home health services to the patients who did not need skilled nursing services. Findings: a. During a review of Patient 5’s Patient Information sheet indicated a start of care date of 2/7/2024. During a review of Patient 5’s Home Health Certification and Plan of Care (POC) form for the certification period from 2/07/2024 to 4/06/2024, indicated patient’s diagnoses which includes hereditary and idiopathic neuropathy (an inherited condition that causes numbness, tingling and muscle weakness in the limbs), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). The POC indicated an order for the skilled nurse (SN) to visit the patient two times a week for 2weeks, and then once a week for 7 weeks for comprehensive skilled nursing assessment, observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. The goal included patient will be free of any falls/injuries/hospitalizations, skin integrity will remain intact, patient maintaining vital signs within normal parameters, and patient/pcg (patient caregiver) will verbalize the effects of prescribed medications and demonstrate compliance with medication/diet. Discharge planning indicated to discharge when patient able to understand medication regimen, when medical condition stabilizes, and when maximum functional potential is reached. During a joint home visit, on 5/30/2024 at 10:25 a.m., conducted at Patient 5’s residence with the registered nurse (RN 2), Patient 5 was observed awake, alert, oriented x3 (to person, place, and time), and ambulatory using a walker. During an interview, Patient 5 stated he was independent with ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), his blood pressure was controlled with medications, has no falls, no wounds, no hospitalization, and goes to his doctors’ appointment regularly. During review of Patient 5’s SN visit Clinical Notes for the month of March 2024, indicated Patient 5’s vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. However, Patient 5 was re-certified for another 60 days for continuous skilled nursing services. During an interview, on 5/31/2024, at 12:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated Patient 5 had no recent hospitalization, no falls, no wound care, no rehabilitation therapy, and should have been discharged. b. During a review of Patient 6’s Patient Information sheet indicated a start of care date of 2/17/2024. During a review of Patient 6’s Home Health Certification and Plan of Care form for the certification period from 2/17/2024 to 4/16/2024, indicated patient’s diagnoses that includes polyarthritis (is present when four or more joints in the body are painful and inflamed), hypertensive heart disease, and hypothyroidism (a condition in which the thyroid gland doesn’t produce enough thyroid hormone causing major symptoms such as fatigue, cold sensitivity, and unexplained weight gain). The POC indicated an order for the skilled nurse (SN) to visit the patient once a week for 1 week, then twice a week for 2 weeks, and then once a week for 6 weeks for comprehensive skilled nursing assessment, observation and evaluation of all body systems, assessment of vital signs, pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. The goal included patient will be free of any falls/injuries/hospitalizations, skin integrity will remain intact, patient maintaining vital signs within normal parameters, and patient/patient caregiver will verbalize the effects of prescribed medications and demonstrate compliance with medication/diet. Discharge planning indicated to discharge when patient able to understand medication regimen, when medical condition stabilizes, and when maximum functional potential is reached. During a joint home visit, on 5/30/2024 at 11:30 a.m., conducted at Patient 6’s residence with the registered nurse (RN 2), Patient 6 was observed awake, alert, and oriented x3 (to person, place, and time). During an interview, Patient 6 stated she prepares and takes her medication daily, have good family support at home, had no hospitalization, no wounds, blood pressure controlled with medications, and family member drives her to her doctors’ appointment regularly. During review of Patient 6’s SN visit Clinical Notes for the month of March 2024 and April 2024, indicated Patient 6’s vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. However, Patient 6 was re-certified for another 60 days for continuous skilled nursing services. During an interview, on 5/31/2024, at 12:15 p.m., with the DPCS, the DPCS stated Patient 6 had no recent hospitalization, no falls, no wound care, no rehabilitation therapy, and should have been discharged. During a review of the agency’s policy and procedure titled, “Discharge Criteria and Process”, revised November 2020, indicated the purpose of the policy is to outline the process for discharging a patient from service. Services will be terminated when the patient meets one of the following discharge criteria: if appropriate, the physician and the organization agree that the goals of home care have been attained or are no longer attainable. a. During a review of Patient 1’s Patient Information sheet indicated a start of care date of 2/7/2024. During a review of Patient 1’s Home Health Certification and Plan of Care (POC) form for the certification period from 3/10/2024 to 5/8/2024, indicated patient’s diagnosis which included bilateral osteoarthritis (occurs when flexible tissue at the ends of bones wears down). The POC indicated an order for the skilled nurse (SN) to visit the patient two times a week for 2 weeks, and then once a week for 7 weeks for comprehensive skilled nursing assessment, observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. The goal included patient will be free of any falls/injuries/hospitalizations, skin integrity will remain intact, patient maintaining vital signs within normal parameters, and patient/pcg (patient caregiver) will verbalize the effects of prescribed medications and demonstrate compliance with medication/diet. Discharge planning indicated to discharge when patient able to understand medication regimen, when medical condition stabilizes, and when maximum functional potential is reached. During a joint home visit, on 5/30/2024 at 11 a.m., conducted at Patient 1’s residence with the registered nurse (RN 1), Patient 1 was observed awake, alert, oriented x3 (to person, place, and time), and ambulatory without using an assistive device. During an interview, Patient 1 stated she was independent with ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating), her blood pressure was controlled with medications, has no falls, no wounds, no hospitalization, and goes to his doctors’ appointment regularly. Patient 1 also stated her son lives with her and takes good care of her. During review of Patient 1’s SN visit Clinical Notes from dates 3/10/2024 to 5/1/2024, indicated Patient 1’s vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. However, Patient 1 was re-certified for another 60 days for continuous skilled nursing services. b. During a review of Patient 2’s Patient Information sheet indicated a start of care date of 2/27/2024. During a review of Patient 2’s Home Health Certification and Plan of Care (POC) form for the certification period from 2/27/2024 to 4/26/2024, indicated patient’s diagnosis which included hypertension ( a condition in which the force of the blood against the artery walls is too high). The POC indicated an order for the skilled nurse (SN) to visit the patient two times a week for 2 weeks, and then once a week for 7 weeks for comprehensive skilled nursing assessment, observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. The goal included patient will be free of any falls/injuries/hospitalizations, skin integrity will remain intact, patient maintaining vital signs within normal parameters, and patient/pcg (patient caregiver) will verbalize the effects of prescribed medications and demonstrate compliance with medication/diet. Discharge planning indicated to discharge when patient able to understand medication regimen, when medical condition stabilizes, and when maximum functional potential is reached. During a phone interview with Patient 2 on 5/30/2024, at 2 p.m., she stated that she ambulates without the use of assistive device, walks everyday around the block for her routine exercise, takes her own medications and had no falls nor hospitalization since admitted to home health services. During review of Patient 2’s SN visit Clinical Notes from dates 2/27/2024 to 4/26/2024, indicated Patient 2’s vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. However, Patient 2 was re-certified for another 60 days for continuous skilled nursing services. c. During a review of Patient 3’s Patient Information sheet indicated a start of care date of 2/22/2024. During a review of Patient 3’s Home Health Certification and Plan of Care (POC) form for the certification period from 2/22/2024 to 4/21/2024, indicated patient’s diagnosis which included osteoarthritis (occurs when flexible tissue at the ends of bones wears down). The POC indicated an order for the skilled nurse (SN) to visit the patient once a week for one week, two times a week for two weeks, once a week for six weeks, for comprehensive skilled nursing assessment, observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. The goal included patient will be free of any falls/injuries/hospitalizations, skin integrity will remain intact, patient maintaining vital signs within normal parameters, and patient/pcg (patient caregiver) will verbalize the effects of prescribed medications and demonstrate compliance with medication/diet. Discharge planning indicated to discharge when patient able to understand medication regimen, when medical condition stabilizes, and when maximum functional potential is reached. During review of Patient 3’s SN visit Clinical Notes from dates 2/22/2024 to 4/21/2024, indicated Patient 3’s vital signs were within a normal range. There were no admissions to the hospital, no episodes of falls, no wound care performed, nor any evidence of the need for skilled nursing services to continue. However, Patient 1 was re-certified for another 60 days for continuous skilled nursing 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) failed to review and document all medication changes and update the medication profile with currently used medications for one of 7 sampled patients (Patient 6). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: During a review of Patient 6’s Patient Information sheet, the Patient Information sheet indicated a start of care (SOC) date of 2/17/2024. During a review of Patient 6’s Home Health Certification (HHC) and Plan of Care (POC) form for certification period 4/17/2024 to 6/15/2024, the HHC and POC indicated patient’s diagnoses included hypertensive heart disease (heart problem that occur because of high blood pressure present over a long time), and hypothyroidism (underactive thyroid). The HHC and POC indicated an order for the skilled nurse (SN) to visit the patient two times a week for 2 weeks, and then once a week for 7 weeks for comprehensive skilled nursing assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services), observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. During a joint home visit, on 5/30/2024 at 11:30 a.m., at Patient 6’s residence with the Registered Nurse (RN 2), Patient 6 was observed awake, alert and oriented x3 (to person, place, and time). During a concurrent interview and review of Patient 6’s current medication, on 5/30/2024 at 12:05p.m. with the RN 2, a bottle of Amlodipine (medicine for high blood pressure) 10 mg (milligram, unit of measure) 1 tablet by mouth daily with a filled date on 3/25/2024, and Levothyroxine (treat hypothyroidism) 50 mcg (microgram) 1 tablet by mouth daily with a filled date on 3/15/2024, were observed. However, the current medication list provided by the HHA indicated Patient 6 was taking Amlodipine 5 mg 1 tablet by mouth daily and Levothyroxine 25 mcg 1 tablet by mouth daily. During the interview with RN 2, RN 2 stated, Patient 6’s medication profile/list was not updated. During an interview, on 5/31/2024, at 12:15 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated patient’s medication profile should have been reconciled and updated on every SN visits. During a review of the agency’s undated policy and procedure titled, “Medication Profile/Reconciliation,” indicated patient receiving medications should have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on observation, interview and record review, the Registered Nurse 1 (RN 1) failed to notify the physician regarding the elevated blood sugar (BS) levels for one of 7 sampled patients (Patient 1), who was diabetic (with abnormal blood sugar levels) and receiving insulin medication (medicine for diabetes). This deficient practice placed Patient 1 at risk for hyperglycemia (high blood sugar levels) crisis. Findings: During a review of Patient 1’s Patient Information sheet, the Patient Information sheet indicated a start of care date of 2/7/2024. During a review of Patient 1’s Home Health Certification (HHC) and Plan of Care (POC) form for certification period 5/8/2024 to 7/7/2024,the HHC and POC indicated a diagnosis of hypertension (high blood pressure). The HHC and POC indicated an order for the skilled nurse (SN) to visit the patient once a week for one week, twice a week for two weeks, once a week for six weeks, for comprehensive skilled nursing assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services), observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. One of the SN interventions was to notify the physician if the BS reading is below 80 and above 300 milligram (mg)/ deciliter (dl). The POC indicated a physician’s order to administer Basaglar 100 units (medicine for diabetes), to inject 15 units subcutaneously daily at bedtime and Novolog 100 units (medicine for diabetes), to inject 5 to 10 units subcutaneously three times daily after meals. During a joint home visit, on 5/30/2024 at 11 a.m., at Patient 1’s residence with the RN 1, Patient 1 was observed awake, alert, oriented x3 (to person, place, and time), and ambulatory without using an assistive device (equipment to assist in walking). RN 1 was observed taking Patient 1’s BS reading with a BS result of 344 mg/dl. During a review of Patient1’s electronic medical record (eMR) on 5/31/2024, at 11 a.m., Patient 1’s EMR did not indicate documented evidence of a communication note that the physician was notified of Patient 1’s elevated BS reading of 344 mg/dl on 5/30/2024. During an interview on 5/31/2024 at 1 p.m. with the Director of Patient Care Services (DPCS) , the DPCS stated she (DPCS) was not aware of Patient 1’s elevated BS result of 344 mg/dl from the home visit on 5/30/2024. The DPCS stated RN 1 should have notified the physician of the blood sugar level of 344 mg/dl on 5/30/2024. The DPCS stated, RN1 should have also reported it to her. A review of home health agency’s undated policy and procedure titled, “Change of Condition,” indicated the clinician is responsible to notify the attending physician of significant changes in the patient’s condition.”

“Patients receive education and training CFR(s): 484.60(d)(5) Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge. This Element is not met as evidenced by: Based on observation, interview and record review, the Home Health Agency (HHA) failed to ensure diabetic management education was provided to Family Member 1 (FM 1) for one of 7 sample patients (Patient 1). This deficient practice had the potential for FM1 not to have knowledge on how to manage the patient during a hypoglycemic (low blood sugar levels)/hyperglycemic (high blood sugar levels) crisis that could affect the patient’s health and safety, resulting to hospitalization or death. Findings: During a review of Patient 1’s Patient Information sheet, the Patient Information sheet indicated a start of care date of 2/7/2024. During a review of Patient 1’s Home Health Certification (HHC) and Plan of Care (POC) form for certification period 5/8/2024 to 7/7/2024, the HHC and POC indicated diagnosis of hypertension (high blood pressure). The HHC and POC indicated an order for the skilled nurse (SN) to visit the patient once a week for one week, twice a week for two weeks, once a week for six weeks, for comprehensive skilled nursing assessment (the required in-person clinical assessment of the patient’s physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency’s services), observation and evaluation of all body systems, assessment of vital signs (measures the basic function of your body that includes your body temperature, blood pressure, pulse and respiratory [breathing] rate), pain level and ability to perform activities of daily living (ADL) tasks, and to evaluate therapeutic response to current/new medications and compliance to medication/diet regimen. One of the SN interventions was to notify the physician if the BS reading is below 80 and above 300 milligrams (mg)/ deciliter (dl) [unit of measurement]. The POC indicated a physician’s order to administer Basaglar 100 units (diabetes [abnormal blood sugar levels] medicine), to inject 15 units subcutaneously daily at bedtime and Novolog 100 units (diabetes medicine), to inject 5 to 10 units subcutaneously three times daily after meals. During a review of Patient 1’s electronic medical record (EMR), the EMR did not indicate documented evidence the visiting nurse had provided patent teachings on diabetic management. The EMR did not indicate a return demonstration (when the learner demonstrate understanding) was performed by FM 1 on how to use the glucometer and how to administer the insulin to Patient 1. During a joint home visit, on 5/30/2024 at 11 a.m., at Patient 1’s residence with the Registered Nurse 1 (RN 1), Patient 1 was observed awake, alert, oriented x3 (to person, place, and time), and ambulatory without using an assistive device (equipment to assist with walking). RN 1 was observed taking Patient 1’s BS reading with a BS result of 344 mg/dl. During a phone interview on 5/31/2024 at 12 p.m. with FM 1, when FM1 was asked if the visiting nurse had provided instructions on how to use glucometer (machine used to check blood sugar levels) and administer insulin for Patient 1, FM1 stated the visiting nurse had not provided instructions on how to use the glucometer. During an interview on 5/31/2024, at 1 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she (DPCS) could not find any documentation from the visiting nurse that patient teaching on diabetic management was provided to Patient 1. During a review of the HHA’s undated policy and procedure (P&P) titled, “ Patient Education Process,” the P&P indicated patients and family/caregiver should receive education in verbal, visual, and written format, as appropriate. The P&P indicated education is the responsibility of each clinician.”