Nelnar Home Health Care, Inc.

“Written instructions to patient include: CFR(s): 484.60(e) Standard: Written information to the patient. The HHA must provide the patient and caregiver with a copy of written instructions outlining: This Standard is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to provide a copy of the recent, and updated plans of care for two of 4 sampled patients (Patient 8 and Patient 10). This deficient practice had the potential to cause the patient and/or the family/caregiver to not knowing their treatment plan, services provided by the HHA, and not being an active participant in their care planning process. a. A review of Patient 8’s “Home Health Certification and Plan of Care” (a written document that outlines the specific needs and services provided to a patient) for the certification period of 3/20/24 to 5/18/24, indicated a start of care date (SOC) of 3/20/24 with a primary diagnosis of polyarthritis (inflammation or degeneration that affects five or more joints). A review of Patient 8’s “Home Health Certification and Plan of Care” for the certification period of 12/28/23 to 2/25/24, indicated the physician ordered the skilled nurse (SN, a licensed nurse in general) to visit Patient 8 once a week for 9 weeks. The SN’s responsibilities included comprehensive skilled nursing assessment, observation, and evaluation of all body systems, assessing vital signs and pain level, and evaluating therapeutic response to current/new medications and compliance to medication/diet regimen, home safety issues, and psychosocial adjustment. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 4/5/24 at 5 p.m., Patient 8 was observed alert, oriented, and ambulatory. When LVN 1 asked Patient 8 for the home folder, Patient 8 stated it was not available. Patient 8 stated that she moved to her current apartment less than a month ago, and she did not know where her home folder was. During an interview with LVN 1 on 4/5/24 at 5:25 p.m., LVN 1 stated patient was supposed to have the home folder. LVN 1 stated the home folder contained a copy of the plan of care, medication profile, and also important telephone numbers the patient could call during an emergency. When asked about the possible negative outcome of patient not having a copy of the plan of care, LVN 1 stated, “If patient doesn’t have the plan of care, they might not know what the goals for them are or the interventions. The plan of care also has the frequency of the visit, just in case patient needs a reminder.” During an interview with the Director of patient Care Services (DPCS) on 4/7/24 at 11:30 a.m., the DPCS stated that patient needed to be provided with a copy of the plan of care so they could participate in their care. The DPCS stated the plan of care had information on the goals, services ordered for the patient, interventions to achieve goals, and the discharge goals. The DPCS stated if the patient did not have the plan of care, then they did not have a reference about their care. The HHA did not provide a policy on providing patients with a copy of plan of care as requested. b. A review of Patient 10’s “Home Health Certification and Plan of Care” (a written document that outlines the specific needs and services provided to a patient) for the certification period of 3/19/2024 to 5/17/2024, indicated a start of care date (SOC) of 3/19/2024 with diagnoses that include of polyarthritis (inflammation or degeneration that affects five or more joints). A review of Patient 10’s “Home Health Certification and Plan of Care” for the certification period of 3/19/2024 to 5/17/2024, indicated the physician ordered the skilled nurse (SN, a licensed nurse in general) to visit Patient 10 once a week for 9 weeks. The SN’s responsibilities included comprehensive skilled nursing assessment, observation, and evaluation of all body systems, assessing vital signs and pain level, and evaluating therapeutic response to current/new medications and compliance to medication/diet regimen, home safety issues, and psychosocial adjustment. During a joint home visit with Licensed Vocational Nurse 2 (LVN 2) on 4/5/24 at 2:00 p.m., Patient 10 was observed alert, oriented, and ambulatory with her walker, sitting comfortably on her chair. When LVN 2 asked Patient 10 for the home health folder, Patient 10 stated it was not available and it is her daughter that keep it for her. Family Member 1 (FM1/Patient 10’s daughter) stated she supposed to bring it today, but she kept it into her home. During an interview with LVN 2 on 4/5/24 at 3:15 p.m., LVN2 stated patient was supposed to have the home folder. LVN 2 stated the home folder contained a copy of the plan of care, medication profile, and important telephone numbers the patient could call during an emergency. When asked about the possible negative outcome of patient not having a copy of the plan of care, LVN 2 stated, “If patient doesn’t have the plan of care, the family might not know what the goals for them are or the interventions. The plan of care also has the frequency of the visit in case patient needs a reminder.” During an interview with the Director of patient Care Services (DPCS) on 4/7/24 at 11:30 a.m., the DPCS stated that patient needed to be provided with a copy of the plan of care so they could participate in their care. The DPCS stated the plan of care had information on the goals, services ordered for the patient, interventions to achieve goals, and the discharge goals. The DPCS stated if the patient did not have the plan of care, then they did not have a reference about their care.”

“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) staff failed to review all the medications and update the medication profile with currently used medications for one of 4 sampled patients (Patient 8). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. A review of Patient 8’s “Home Health Certification and Plan of Care” (a written document that outlines the specific needs and services provided to a patient) for the certification period of 3/20/2024 to 5/18/2024, indicated a start of care date (SOC) of 3/20/24 with a primary diagnosis of polyarthritis (inflammation or degeneration that affects five or more joints). A review of Patient 8’s “Home Health Certification and Plan of Care” for the certification period of 12/28/2023 to 2/25/2024, indicated the physician ordered the skilled nurse (SN, a licensed nurse in general) to visit Patient 8 once a week for 9 weeks. The SN’s responsibilities included comprehensive skilled nursing assessment, observation, and evaluation of all body systems, assessing vital signs and pain level, and evaluating therapeutic response to current/new medications and compliance to medication/diet regimen, home safety issues, and psychosocial adjustment. During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 4/5/2024 at 5 p.m., Patient 8 was observed alert, oriented, and ambulatory. During medication review with LVN 1, the following medications were listed on Patient 8’s medication profile: - Vitamin D3 (a supplement) 50 mcg (2000 unit) capsule, take one capsule daily. - Metformin HCl (medication to treat diabetes) 100 mg, take one tablet orally twice daily. However, the medications available at Patient 8’s had different doses: - Vitamin D3 25 mcg (1000 unit) capsule; patient takes once daily. Metformin HCl 1000 mg, patient takes twice daily. During an interview with Patient 8 at 4/5/2024 at 5:50 p.m., Patient 8 stated she had always taken Metformin 1000 mg twice a day. Patient 8 stated the Metformin dose had not been changed. Patient 8 also stated that she might have taken Vitamin D3 2000 unit before, but she had been taking the current dose for a while. During an interview with LVN 1 on 4/5/2024 at 6 p.m., LVN 1 stated the Metformin dose Patient 8 had been taking was 1000 mg, not 100 mg. LVN 1 stated that it was an error, as Metformin did not come in 100 mg dose. Regarding Vitamin D3, LVN 1 stated the dose for vitamin D3 used to be 2000 units, but she believed it was changed to 1000 units by the physician. When asked why patient’s medication profile needed to be current, LVN 1 stated that it was important to update the medication profile so it would show current medications with the correct dose and frequency. LVN 1 stated if the medication profile was not updated, patient might take a medication that had been discontinued. During an interview with the Director of patient Care Services (DPCS) on 4/7/2024 at 12 p.m., the DPCS stated medication profile needed to be accurate and updated. According to the DPCS, the nurse needs to check patient’s medications with every visit. If there is a change, the medications profile needs to be updated, so it is always current. The DPCS stated, “This is important, so patient knows about the medications they’re supposed to take, and the nurse can give appropriate medication teaching.” A review of the agency’s policy, titled “Medication Profile,” revised November 2017, indicated that patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profile will be updated for each change to reflect current medications and/or discontinued medications.”

“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 interview and record review, the Home Health Agency (HHA) failed to ensure the Condition of Participation (conditions that health care organizations must meet to begin and continue participating in the Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] program) regarding comprehensive assessment (a tool used by nurses to evaluate a patient’s complete health status) was met as follows: 1. The home health agency (HHA) failed to complete the patient’s initial recertification comprehensive assessment within five calendar days of admission for two of seven sample patients (Patient 6 and Patient 7). (Refer to G520). 2. The home health agency (HHA) failed to assess the patient’s continuing need for skilled nursing services for two of seven sample patients. (Patient 5 and Patient 6). (Refer to 522). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (in a way that is decided and controlled by law) compliance with the Federal Regulations for Comprehensive Assessment of Patients to ensure the provision of quality health care services in a safe manner.”

“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 ensure the condition of participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for care planning, coordination, and quality of care was met as follows: 1. The Home Health Agency (HHA) failed to coordinate care and services for diabetes (a medical condition characterized by the body’s inability to regulate blood sugar levels) management and wound care needs for one of seven sampled patients (Patient 2) Refer to G606 2. The home health agency (HHA) failed to maintain the labeling and storage of medications for one of seven sampled patients (Patient 2). refer to G616. The cumulative effect of these systemic practices resulted in the home health agency’s failure to ensure the plan of care was followed to reach Patient 2’s goals.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to complete the patient’s initial recertification comprehensive assessment (a tool used by nurses to evaluate a patient’s complete health status) within five calendar days of admission for two of seven sampled patients (Patient 6 and Patient 7). This deficient practice had the potential to cause delay of patient care and had the potential to place Patient 6 and Patient 7 at risk for complications that could affect their overall health status. Findings: a. A review of Patient 6’s clinical record indicated a start of care (SOC) date of 9/1/2023, with diagnosis that included hypertension (is when the blood pressure, the force of blood flowing through the blood vessels, is consistently too high). During a review of Patient 6’s plan of care (POC) dated from 10/31/2023 to 12/29/2023, the POC indicated an order for the skilled nurse (SN) to visit once a week for nine weeks for assessment of all the body system and medication compliance. During a concurrent interview and record review, on 1/9/2024, at 1 p.m., with Registered Nurse 1 (RN 1), Patient 6’s recertification comprehensive assessment (OASIS- to determine the need for nursing services) dated 10/31/2023 was reviewed. RN 1 stated the HHA’s Registered Nurse (unidentified) did not conduct Patient 6’s comprehensive assessment and stated the RN (unidentified) needed to conduct the comprehensive assessment no later than five calendar days from new episode of care to prevent delay of care. b. A review of Patient 7’s clinical record indicated a start of care (SOC) date of 10/27/2023, with diagnosis that included cellulitis (skin infection caused by bacteria) of the right lower limb (leg). During a review of Patient 7’s plan of care (POC) from 12/26/2023 to 2/23/2024, the POC indicated an order for the skilled nurse (SN) to visit three times a week for nine weeks, for assessment of all body system and medication compliance. During an interview on 1/9/2024, at 1:15 p.m., with RN 1, RN 1 stated the Registered Nurse (unidentified) did not conduct Patient 7’s comprehensive assessment and stated the RN (unidentified) needed to conduct the comprehensive assessment no later than five calendar days from new episode of care to prevent delay of care. A review of the agency’s undated policy “ Re-Assessment/Re-Certification”, indicated for each new episode of care, a comprehensive assessment will be completed no earlier than five days before and no later than one day before the calendar day on which the new episode of care began.”

“Eligibility for Medicare home health benefit CFR(s): 484.55(b)(2) Except as provided in paragraph (b)(3) of this section, a registered nurse must complete the comprehensive assessment and for Medicare patients, determine eligibility for the Medicare home health benefit, including homebound status. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to assess the patient’s continuing need for skilled nursing services for two of seven sampled patients (Patient 5 and Patient 6). This deficient practice had the potential for Patient 5 and Patient 6 to receive unnecessary continuous home health services. Findings: a. A review of Patient 5’s clinical record indicated a start of care (SOC) date of 9/29/2023, with diagnosis that included hypertension (is when the blood pressure, the force of blood flowing through the blood vessels, is consistently too high). During a review of Patient 5’s Plan of Care (POC) from 9/29/2023 to 11/26/2023, the POC indicated an order for the skilled nurse (SN) to visit of once a week for nine weeks for assessment of all body system and medication compliance. The POC indicated the discharge planning was to discharge Patient 5 when medical condition was stable and the patient no longer needed skilled care. During a review of Patient 5’s initial comprehensive nursing assessment for recertification (OASIS- to determine the need for nursing services) dated 9/29/2023, the OASIS indicated Patient 5 had aching pain on the right knee with the pain level 4 (mild to moderate) on a pain scale from zero (no pain) to ten (worse pain) less than daily. The OASIS indicated medication, heat, and rest relieved Patient 5’s pain. During an observation on 1/10/2024, at 12 p.m., a home visit was made to Patient 5’s and Patient 6’s residence. Patient 5 was observed alert, oriented, and walking without using any assistive device. During an interview with Patient 5 on 1/10/2024, at 12:15 p.m., Patient 5 stated she cooked and prepared medications for Patient 6. b. A review of Patient 6’s clinical record indicated a start of care (SOC) date of 9/1/2023, with diagnosis that included hypertension. During a review of Patient 6’s plan of care (POC) from 9/1/2023 to 11/28/2023, the POC indicated an order for the skilled nurse (SN) to visit of once a week for nine weeks for assessment of all body system and medication compliance. The plan of care indicated the discharge planning was to discharge Patient 6 when the patient’s medical condition was stable, and the patient no longer needed skilled care. During a review of Patient 6’s Nursing Progress Notes from 9/1/2023 to 11/26/2023, the Nursing Progress Notes indicated the patient experienced pain at a level of 4/10 to 6/10 (moderate pain), and the pain level decreased from 0/10 to 3/10 after intervention. The Nursing Progress Notes indicated Patient 6’s vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient’s essential body functions) were within a normal range. The Nursing Progress Notes indicated there were no admissions to the hospital, no episodes of high blood pressure or any evidence of the need for skilled nursing services to continue. During an observation on 1/10/2024, at 12:30 p.m., at Patient 6’s home, Patient 6 was alert, oriented, and was lying on the couch in the living room. During an interview on 1/10/2024, at 12:40 p.m., with Patient 6, Patient 6 stated Patient 5 prepared the medications and would check his blood pressure readings which were in normal ranges. During an interview on 1/10/24, at 4:30 p.m., with Registered Nurse 1 (RN 1), RN 1 stated Patient 5 and Patient 6, who were husband and wife were incompliance with their medication regimen, so the agency decided to re-certify them for another 60 days for continuous SN (skilled nurse) monitoring and patient teaching. A review of the agency’s policy titled “Discharge Criteria and Process” indicated services will be terminated when the goals of home health have been attained or are no longer attainable.”

“Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This Element is not met as evidenced by: Based on observation, interview, and record review, the Home Health Agency (HHA) failed to coordinate care and services for diabetes (a medical condition characterized by the body’s inability to regulate blood sugar levels) management and wound care needs for one of seven sampled patients (Patient 2). This deficient practice had the potential not to meet Patient 2’s needs and could affect Patient 2’s safety and treatment effectiveness. Findings: During a review of Patient 2’s Home Health Certification and Plan of Care (POC), indicated the HHA admitted Patient 2 on 5/19/2023 with diagnoses including Type 2 diabetes (a medical condition characterized by the body’s inability to regulate blood sugar levels) with a foot ulcer (a damaged area on the foot). During a review of Patient 2’s Home Health Certification and Plan of Care (POC), with the certification period reviewed from 11/15/2023 to 1/13/2024, the Home Health Certification and Plan of Care indicated Patient 2 was homebound (unable to leave one’s house) due to Patient 2 needed assistance for all activities. The Home Health Certification and Plan of Care indicated Patient 2’s Care Giver (PCG) assumed DM responsibilities, was confident, capable, and competent in checking blood sugar twice daily, able to calibrate (is to help assure precise measurements) the glucometer (portable machine that is used to measure how much glucose [a type of sugar] is in the blood). The Home Health Certification and Plan of Care indicated the patient required further teachings on diabetic management. SN to record blood sugar test results checked by patient/patient caregiver during the visits and report any significant changes to the doctor. During a review of Patient 2’s Progress Notes, dated 11/7/2023, the Progress Notes indicated the wound specialist recommended the following: an x ray (imaging creates pictures of the inside of your body) (unidentified body part), aggressive offloading (minimizing or removing weight placed on the foot to help prevent and heal), reposition Patient 2 every two hours, frequent adult brief (disposable underwear) checks and changes, and a low air loss mattress (LAL, mattress that operates using a blower based pump that was designed to circulate a constant flow of air). The progress notes indicated recommendations for Patient 2 to receive Juven (targeted nutrition therapy to support wound healing in patients with inadequate nutrition sores, such as those with diabetic wounds [like foot ulcers], surgical wounds, burns, and other wounds) for wound healing, a high protein-calorie diet, and refer to the primary care physician (PCP). During a review of Patient 2’s Home Health Certification and Plan of Care (POC) with the certification period reviewed from 11/15/2023 to 1/13/2024, the Home Health Certification and Plan of Care (POC) indicated for the SN/PCG to administer Humalog injections and record blood sugar levels. During a review of Patient 2’s undated wound care notes, the wound care notes indicated a wound care specialist went to the patient’s home every week to do a debridement (medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) and wound care. During an observation on 1/10/2024, at 11a.m., inside Patient 2’s home with the Director of Nursing Designee (DOND), Patient 2 was lying in bed, alert, and oriented to name, place, and person, with episodes of sadness manifested by crying. During the concurrent interview on 1/10/2024, at 11a.m., with the DOND, the DOND stated Patient 2’s PCG did not want to check Patient 2’s blood sugar levels. DOND stated the HHA would send a nurse (in general) to check Patient 2’s blood sugars three times a day. The DOND stated the HHA did not refer Patient 2 to outside resources to help with the blood sugar checking. The DOND stated the HHA did not offer a digital blood sugar monitor device (continuous blood sugar monitoring system with optional, real-time alarm that let you know the minute your blood sugar level is too low or too high without having to do a fingerstick [the drawing of blood from the fingertip]) to Patient 2. The DOND stated she could not find the list of Patient 2’s blood sugar monitoring. During an interview on 1/10/2024, at 11:01 am, with Patient 2, Patient 2 stated the HHA did not send a social worker to his home. Patient 2 stated he used to check his blood sugars even after he had history of stroke (when blood flow to the brain is blocked or there is sudden bleeding in the brain) but now he was weak and was not able to check his blood sugar by himself. Patient 2 stated PCG did not help him to check his blood sugar. Patient 2 stated he would like an easier way to monitor his blood sugar using a digital monitor without having to do a fingerstick three times a day. Patient 2 stated the HHA did not offer the option of a digital blood sugar monitor. During an interview on 1/11/2024, at 10:10 a.m., with DOND, DOND stated the HHA did not send the wound care specialist’s recommendations to Patient 2’s Primary Care Physician (PCP unidentified). DOND stated the HHA doctor (unidentified) agreed with the wound specialist recommendations and the DOND stated the HHA needed to refer the recommendations to the PCP to help reach Patient 2’s goals. A review of the HHA’s policy titled “ Coordination of Services with Other Providers,” dated 11/2017 indicated to ensure the coordination of services provided by the organization and by other service providers. The Case Manager will be responsible for coordinating services provided to the patient by the organization, including services provided directly and through contract. The Case Manager will act as liaison with other organizations or individuals also providing care to the patient to ensure effective coordination of related services. Other providers and all referrals to other service providers will be documented in the clinical record. The other service provider will be responsible to contact the physician (or other authorized licensed independent practitioner) for orders for its evaluation and treatment. The Case Manager or Clinical Supervisor will be responsible for the coordination between service providers, which will include, but not be limited to: Organization personnel’s understanding of each organization’s/individual’s responsibility in providing care. Initiation of communication with other organizations/individuals when there are significant changes in the patient’s care, treatment, or services. Sharing relevant information to facilitate coordination and continuity of care and to avoid duplication of services. Ongoing communication regarding specific patients will be the responsibility of the Case Manager or the appropriate clinician. Ongoing communication regarding issues and concerns with the organizations or individuals providing care will be the responsibility of the agency’s management. The physician will be contacted to verify the continued need for care, his/her agreement with the continued plan of care and an estimate of how much longer the skilled services will be required. An interim order to continue home health services will be prepared and sent to the physician (or other authorized licensed independent practitioner) for his/her signature. The updated plan of care will be prepared and sent to the physician for review and signature in a timely manner.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure home visits were conducted in accordance with the plan of care (POC) for one out of seven sampled patients (Patient 3) who was discharged administratively. This deficient practice had the potential to negatively affect Patient 3’s physical comfort, psychosocial well-being, and not receive the needed and necessary services timely. Findings: During a review of Patient 3’s Admission Record, the Admission Record indicated a start of care date (SOC) of 6/13/2023, with a terminal diagnosis of malignant neoplasm of the cervix (cancer of the cervix, the lower end of the womb) and encounter for adjustment and management of vascular access device (PICC- peripherally inserted central catheter, a type of long catheter that is inserted through a vein, often in the arm, into a larger vein in the body, used when intravenous treatment is required over a long period usually for chemotherapy). During a review of the HHA’s Patient Assessment Oasis: Discharge signed and dated on 9/26/2023, timed at 6:11 p.m., by the Registered Nurse Case Manager (RNCM), indicated there was no assessment performed and documented on Section O: Special Treatment, Procedures and Programs: C. at discharge Cancer treatments A1 chemotherapy O4. Central (e.g. PICC, tunneled, port). None of the above had a check mark. During a review of the HHA’s documentation on Patient 3’s electronic medical record on 1/11/2024, indicated Patient 3 was discharged on 9/25/2023 stating the agency received a phone call from the skilled nurse (unidentified) was unable to reach the patient. “Please discharge the patient from home care services. MD notified. Order/Telephone Orders: Discharge patient administratively effective today.” During an interview and concurrent record review on 1/11/2024, at 10:10 a.m., with the Director of Nursing Designee (DOND) Patient 3’s record was reviewed. The DOND stated the agency learned patient 3 went to the clinic for rehydration (the process of restoring lost water). DOND stated the nurses (in general) and the office would call the patients (in general). The DON stated and if the patients did not reply, the next of kin and if no reply, the HHA would call the doctor and ask if they saw the patient. DOND stated that it should be written in the clinical record if they could not get a hold of the patient and the reason. DOND stated patient care visit should have been provided to Patient 3 in accordance with the HHA’s policy and the plan of care. During a review of the agency’s policy and procedure titled, “Case Conference/Progress Summary”, revised 11/2017, indicated To define the process for case conferences and documenting patient progress in the clinical record. Case conferences will be held at least every 60 days to review and discuss all multidisciplinary cases. Items of discussion will include, but will not be limited to, the type and frequency of service by each discipline involved, changes in the patient’s overall status, problems, possible resolutions, progress toward goals and any necessary revisions in the plan of care. Case conferences will include utilization review; therefore, all clinicians working with patients will participate in case conferences. Each multidisciplinary patient will have a case conference during the month following the certification month. For each patient, the clinician will lead the conference and discuss: A. Physical status of the patient B. Clinical implications of diagnoses and treatment prescribed C. Patient treatment choices D. Changes in condition since last conference E. Interventions for all disciplines and patient response F. Current frequency versus ordered frequency of all disciplines in the case G. Progress toward goals H. Teaching plan and its effectiveness I. Discharge plan If a patient is routinely refusing visits, the clinician and clinical supervisor should evaluate the appropriateness of the plan of care and make adjustments to the plan of care with input from the patient and physician. A review of the HHA’s policy titled “Missed Visits” dated 11/2017 indicated If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled the clinician will: Notify the physician and clinical supervisor of the missed visit and reason for missed visit Document in the patient’s clinical record the following information: Patient name, Date and type of visit that was missed , Reason for the missed visit ,Description of any unmet needs and how the patient’s needs were met ,Physician notification including date, time, physician name, method of notification and the staff reporting the information ,Any other follow-up needed ,Other person(s) that were notified of the missed visit ,Signature of staff member reporting the information. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to maintain accurate labeling and storage for one of seven sampled patients (Patient 2). This deficient practice had the potential to place Patient 2 at risk for medication errors, adverse drug reactions (is a harmful, unintended result caused by taking medication), and ineffective administration of medications. Findings: During a review of Patient 2’s Home Health Certification and Plan of Care (POC), indicated the HHA admitted Patient 2 on 5/19/2023 with diagnoses including Type 2 diabetes (a medical condition characterized by the body’s inability to regulate blood sugar levels) with a foot ulcer (a damaged area on the foot). During a review of Patient 2’s Home Health Certification and Plan of Care (POC), with the certification period reviewed from 11/15/2023 to 1/13/2024, the Home Health Certification and Plan of Care indicated Patient 2 was homebound (unable to leave one’s house) due to Patient 2 needed assistance for all activities. The Home Health Certification and Plan of Care indicated Patient 2’s Care Giver (PCG) assumed DM responsibilities, was confident, capable, and competent in checking blood sugar twice daily, able to calibrate (is to help assure precise measurements) the glucometer (portable machine that is used to measure how much glucose [a type of sugar] is in the blood). The Home Health Certification and Plan of Care indicated the patient required further teachings on diabetic management. SN to record blood sugar test results checked by patient/patient caregiver during the visits and report any significant changes to the doctor. During an observation on 1/10/2024, at 11a.m., inside Patient 2’s home with the Director of Nursing Designee (DOND), Patient 2 was lying in bed, alert, and oriented to name, place, and person, with episodes of sadness manifested by crying. During a concurrent medication review and interview on 1/10/2024, at 11 am, with the DOND, Patient 2’s Medication Profile was reviewed. The DOND stated Patient 2 was taking Humalog (fast-acting insulin [helps the body turn food into energy and controls the blood sugar levels used to control high blood sugar) 100 unit/milliliter (a unit of measurement) per sliding scale (varies the dose of insulin based on blood glucose level). DOND stated Patient 2 required blood sugar checks three times daily before meals. DOND Patient 2’s Medication Profile indicated if Patient 2’s blood sugar was less than 149 milligrams per deciliter (mg/dL, a unit of measurement), no insulin, if blood sugar was between 150-199 mg/dL may give one unit of Humalog insulin, if the blood sugar was between 200-249 mg/dL may give two units of Humalog insulin , if between 250-299mg/dL may give three units of Humalog insulin, if the blood sugar was between 300-349 mg/dL may give four units of Humalog insulin, if blood sugar was more than 400 mg/dL to call the doctor. The DOND stated she could not find Patient 2’s insulin inside Patient 2’s refrigerator. The DOND stated she could not find the list of Patient 2’s blood sugar monitoring. During a phone interview on 1/10/2024, at 3:15 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she checked Patient 2’s blood sugar three times a day and administered the insulin as ordered. LVN 1 stated the insulin was located behind Patient 2’s PCG’s medications inside the refrigerator. LVN 1 stated Patient 1 had one insulin pen injector and she ordered from the pharmacy prior the home visit. LVN 1 stated the insulin pen injector did not have any label or a box. LVN 1 stated Patient 2’s PCG threw the box of the medication. A review of the HHA’s policy titled “ Medication profile” dated 11/2017 indicated that Patients receiving medications will 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. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to: A. Using the medication profile, in conjunction with other pertinent data, to evaluate the use of the drugs in the home setting B. Using the medication profile to teach the purpose of medication, dosages, routes, administration times, side effects, and contraindications C. Using the medication profile as a communication tool for other clinicians involved in care.”