Complete Home Health Care LLC

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on record review and interviews, the agency failed to ensure each patient received care as ordered by their physician in 4 of 9 active patient records reviewed (Patients #2, #5, #8 and #9). Findings include: 1. The clinical record for Patient #5 was reviewed on 5/5/25. The POC for the certification period dated 1/15/25 to 3/15/25, signed by Patient #5’s physician on 2/27/25, revealed a start of care date of 1/15/25; diagnosis included: Type 2 diabetes mellitus with hyperglycemia, hypertension, hyperlipidemia, atherosclerotic heart disease, tobacco use, long-term use of injectable non-insulin antidiabetic medication, long-term use of oral hypoglycemic medication, and long-term use of antithrombotics/antiplatelets. Plan of care orders included skilled nurse (SN) visits one time a week for nine weeks and five as needed (PRN) visits for the following: assessment; medication education and management including use, dose, frequency, side effects and when to call MD [medical doctor]/911; patient/caregiver assessment and education on diabetic foot care, fall risk, on administering Trulicity injectable medication (diabetes medication for adults that helps a body release its own insulin and can help improve a patient’s blood glucose (BG)), proper disposal of sharps, on correct use of a medication planner, on expressing satisfaction/dissatisfaction of pain regimen and follow up with MD, and on use of both prescriptive and non-prescriptive pain medication; and SN to fill medication planner (no frequency provided). The POC for the certification period dated 3/16/25 to 5/14/25, signed by Patient #5’s physician on 4/24/25, revealed a start of care date of 1/15/25; diagnosis included: Type 2 diabetes mellitus with hyperglycemia, hypertension, hyperlipidemia, atherosclerotic heart disease, tobacco use, long-term use of injectable non-insulin antidiabetic medication, long-term use of oral hypoglycemic medication, and long-term use of antithrombotics/antiplatelets. Plan of care orders included SN visits one time a week for three weeks for the following: assessment; medication education and management including use, dose, frequency, side effects and when to call MD/911; patient/caregiver assessment and education on diabetic foot care, on fall risk, on administering insulin injectable medication, proper disposal of sharps, on correct use of medication planner, on expressing satisfaction/dissatisfaction of pain regimen and follow up with MD, and on use of both prescriptive and non-prescriptive pain medication; and SN to fill medication planner (no frequency provided). Review of a 3/17/25 transfer to inpatient facility assessment revealed Patient #5 was admitted to the hospital for an unknown reason. Review of a 3/22/25 resumption of care, after inpatient stay, assessment revealed registered nurse (RN) #9 received a verbal order from Patient #5’s physician for medication and plan of care changes including wound care orders for his right toe amputation and orders for the addition of several new medications including insulin glargine (a long-acting type of insulin used to control high BG in people with diabetes - brand names include: Lantus, Basaglar, Toujeo, Semglee, Rezvoglar) and insulin lispro (a rapid-acting type of insulin used manage high BG in people with diabetes - brand names include: Humalog, Ademlog, Lyumjev). Review of a 3/21/25 hospital discharge referral paperwork revealed Patient #5 was to stop injecting Trulicity 3 milligrams (mg)/0.5 milliliters (ml) once per week and to take the following medications: -Abilify, two mg, take one tablet by mouth daily; -Gabapentin, 800 mg, take one tablet by mouth three times a day; -Lipitor, 80 mg, take one tablet by mouth daily -metformin HCI, 1000 mg, take one tablet by mouth twice a day; -Plavix, 75 mg, take one tablet by mouth daily; -Protonix, 20 mg, take one tablet by mouth daily; -Trazodone HCI, 50 mg, take one tablet by mouth daily; -famotidine, 20 mg, take one tablet by mouth daily; -fluticasone propionate, 50 micrograms(mcg)/actuation, two nasal sprays daily as needed; -glipizide,10 mg, take one tablet by mouth daily; -amoxicillin-clavulanate (brand name - Augmentin), 875-125 mg, take one tablet by mouth twice a day with meals for 14 days; -insulin glargine (brand name - Lantus Solostar) 100 unit/ml (3 ml), inject 15 units into the skin daily and 10 units nightly at bedtime; -insulin lispro (brand name -Humalog), 100 unit/ml pen injection, provide for uncontrolled diabetes mellitus type 2, inject three times daily before meals and at bedtime as follows:- BG 70 to 150 give zero units; 151-200 give two units; 201 to 250 give four units; 251-300 give six units; 301-350 give eight units; 351-400 give 10 units and over 400 give 12 units and call physician; -polyethylene glycol packet, 17 grams (g), take by mouth daily mixed in with four to eight ounces of water as needed for constipation; -senna-docusate, 8.6 - 50 mg, take two tablets by mouth two times daily for constipation; -glipizide, 10 mg, take one tablet by mouth daily; -lisinopril, 20 mg, take one tablet by mouth daily; and -oxycodone, 15 mg immediate release tablet, take one tablet by mouth every eight hours as needed for acute pain. Review Patient #5’s 3/22/25 supplemental orders, written by RN #9, showed Patient #5 was to stop his once weekly Trulicity injections and was to add the following medications: -insulin lispro subcutaneous solution, pen-injector 100 unit/m,l 15 units daily subcutaneously in the morning; -insulin lispro subcutaneous solution, pen-injector 100 unit/ml, 10 units daily subcutaneously in the evening; -insulin glargine, 100 unit/ml pen injection, provide for uncontrolled diabetes mellitus type 2 three times a day as follows: BG 70 to 150 give zero units; 151-200 give two units; 201 to 250 give four units; 251-300 give six units; 301-350 give eight units; 351-400 give 10 units and over 400 give 12 units and call physician; -Augmentin, 500 - 125 mg, take one tablet twice a day by mouth ending on 4/5/25; - Glucotrol XL (generic name - glipizide) extended release 24 hour, 10 mg, take one tablet by mouth with a note stating Patient #5’s insurance would not cover this medication: and -oxycodone HCI, 15 mg, take one tablet as needed by mouth every eight hours for pain. Further review of Patient #5’s 3/22/25 supplemental orders showed RN #9 wrote the orders for insulin lispro as insulin glargine and insulin glargine as insulin lispro. Additionally the supplemental orders failed to show Patient #5 was to take famotidine, fluticasone propionate, lisinopril, polyethylene glycol and senna-docusate. Cross Reference G708 a) The agency failed to ensure Patient #5 received SN visits as ordered. Review of a 3/22/25 clinical note, written by RN #9, revealed RN #9 attempted to teach Patient #5 how to self inject insulin glargine and insulin lispro, but Patient #5 was unable to self-inject these two medications due to his poor depth perception and dislike of needles. RN #9 documented Patient #5 stated he was not comfortable with injecting his two insulin medications and did not feel he could accurately follow the sliding scale provided for administration of his ordered Humalog (insulin lispro). Review of a 3/28/25 supplemental order, written by the assistant director of nursing (ADON), signed on 3/28/25 by Patient #5’s physician, showed Patient #5’s SN visits were to increase to three times a day to assist him with administration of insulin. Review of a supplemental order, written by RN #9 on 4/4/25 at 8:01 a.m. , and not signed by Patient #5 physician, showed Patient #5’s SN visit frequency was requested to change to three times a day for 41 days, effective 4/4/25. Review of SN visit notes, from 3/22/25 through 5/4/25, showed Patient #5 received SN visits three times a day as ordered from 3/28/25 through 5/4/25, except for the following days: -3/28/25 - 3/31/25, 4/2/25, and 4/3/25, Patient #5 failed to receive any SN visits without documentation why these visits were missed or how Patient #5’s needs were met; -4/1/25, Patient #5 received one visit from RN#9, from 10:15-10:35 a.m., and Patient #5’s record failed to show why he did not receive the other two ordered SN visits on 4/1/25 or how his needs were met during those two missed visits; -4/9/25, Patient #5 failed to receive his morning visit as he was not home for the scheduled visit; -4/10/25, Patient #5 failed to receive his noon visit as he was not home for the scheduled visit; and -4/27/25, Patient #5 failed to receive his evening visit with Patient #5’s record failing to show documented evidence why this visit was missed or how Patient #5’s needs were met during this missed visit. During a home visit on 5/6/25 at 4:46 p.m., Patient #5 confirmed he started to receive home health care from the agency in January of 2025. Patient #5 stated when he first started to receive care from the agency, RN #9, his primary SN, provided him care one time a week to help him learn how to inject Trulicity and to help Patient #5 improve his medication compliance. Patient #5 stated in mid-March of 2025, he developed a painful blister on one of his right toes. Patient #5 stated he failed to inform RN #9 about his painful right toe blister. Patient #5 stated instead, he sought care for the painful right toe blister from the emergency room and was admitted to the hospital. Patient #5 was found to have an infection in the bone of his right toe with the painful blister. Patient #5 stated he underwent a right toe amputation and was sent home on 3/21/25 with two new types of insulin, insulin glargine and insulin lispro, to help reduce/control his BG. Patient #5 stated RN #9 attempted to teach him how to administer the insulin glargine and insulin lispro, but he struggled with how to draw the medicine up accurately. Patient #5 stated RN #9 coordinated SN visits three times a day to assist Patient #5 with this task. Patient #5 stated the agency SNs always provided him care three times a day and he had never experienced any no call/no show visits from the agency. During an interview on 5/7/25 at 10:31 a.m., RN #9 confirmed he was Patient #5’s RN case manager. RN #9 stated from 1/15/25 until 3/17/25, RN #9 provided Patient #5 with visits one time a week as ordered. RN #9 stated Patient #5 had successfully learned how to inject Trulicity once a week during visits conducted 1/15/25 to 3/17/25. RN #9 stated when Patient #5 returned from the hospital on 3/21/25, his discharge paperwork showed Patient #5 was to inject Lantus (insulin glargine) two times a day and Humalog (insulin lispro) four times a day using a sliding scale for dosing. RN #9 stated he attempted to teach Patient #5 how to inject Lantus and Humalog during his 3/22/25 resumption of care assessment visit, but Patient #5 struggled with this task due to poor depth perception and his dislike of needles. RN #9 stated he called Patient #5’s physician for orders to increase SN visits to three times a day. RN #9 stated the agency did not provide visits after 5 p.m., and Patient #5’s physician approved Patient #5 to receive his Humalog (insulin lispro) three times a day instead of four times a day as ordered on the discharge paperwork. RN #9 stated he informed the ADON Patient #5 would require visits three times a day, but stated Patient #5 did not receive visits three a day until 4/4/25 as the agency was waiting for approval from Patient #5’s insurance company. During continued interview, RN #9 stated on 4/27/25, he was the SN on-call for the agency. RN #9 stated he failed to provide Patient #5 with care during the evening visit of 4/27/25 as the visit was on his schedule, but not on RN #9’s calendar. RN #9 stated he did not complete a missed visit for this shift nor notify Patient #5’s physician of the missed visit, but he thought someone in the office would complete this missed visit and notify Patient #5’s physician. During an interview on 5/7/25 at 2:03 p.m., the ADON confirmed RN #9 informed her of Patient #5’s need for SN visits to increase to three times a day after he completed Patient #5’s resumption of care assessment visit on 3/22/25. The ADON confirmed the agency typically did not provide visits after 5:00 p.m. The ADON stated if the agency received an order for visits after 5:00 p.m. for a diabetic patient, the agency instructed the SN who received the order, to discuss with the ordering physician if the patient could receive a long-acting insulin to provide BG control in lieu of a visit after 5:00 p.m.; and/or to see if the patient had a family member who could assist the patient with administration of medications after 5:00 p.m. The ADON stated RN #9 failed to inform her Patient #5’s Humalog was ordered to be administered three times before meals and again at bedtime on his 3/21/25 hospital discharge referral paperwork. The ADON stated when RN #9 received permission from Patient #5’s physician to change the administration of Humalog from four times a day to three times a day, he should have documented this approval in Patient #5’s record. The ADON stated RN #9 failed to document this approval to change Patient #5’s SN visit frequency in Patient #5’s record, until he documented a 4/4/25 supplemental order to change Patient #5’s SN visit frequency. During continued interview, the ADON reviewed the supplemental order she wrote for Patient #5 on 3/28/25 to increase Patient #5’s SN visit frequency to three times a day. The ADON acknowledged this order was signed by Patient #5’s physician on 3/28/25, and thus, was an active order as of 3/28/25. The ADON stated the agency was waiting for insurance approval prior to providing the three times a day SN visits, which the agency received on 4/4/25. The ADON acknowledged Patient #5’s record failed to show documented evidence Patient #5’s physician was informed of the delay in providing visits three times a week, and thus, the agency failed to follow physician orders for SN visits. The ADON also acknowledged Patient #5’s record failed to show documented evidence why he did not receive a SN visit the evening of 4/27/25. The ADON was unable to provide the surveyor with a reason why this visit was not provided to Patient #5. The ADON stated she was unaware the visit was missed due to RN #9 failing to see the visit on his schedule. The ADON stated RN #9 should have completed a missed visit for this visit and notified the physician of the missed visit. b. The agency failed to ensure Patient #5’s physician was notified when Patient #5’s BG was out of the ordered parameter range. Review of an unsigned supplemental order, dated 3/17/25 to 5/14/25, revealed on 3/22/25, RN #9 provided care coordination with on-call staff at Patient #5’s physician regarding resumption of care plan of care orders for the following: a treatment intervention, dated 3/22/25, showed SN were to call Patient #5’s physician if his BG was less than 60 or greater than 350; and on 3/22/25 the medication insulin glargine Solostar Subcutaneous was added with the precaution to call Patient #5’s physician if his BG was over 400. Cross Reference G708 Review of SN visits from 3/22/25 through 5/4/25 showed SNs documented Patient #5’s BG was over 400 and SNs failed to notify Patient #5’s physician six times and Patient #5’s BG was over 350 and SNs failed to notify Patient #5’s physician on the following 18 dates: -on 4/5/25, during the 1:05 p.m. to 1:15 p.m. SN visit, RN #11 documented Patient #5’s BG was 376 and no contact was made with Patient #5’s physician; -on 4/8/25, during the 9:00 a.m. to 9:30 a.m. SN visit, RN #10 documented Patient #5’s BG was 464. RN #10 documented Patient #5 showed no symptoms of his elevated BG and she educated Patient #5 on signs and symptoms of diabetic ketoacidosis (DKA- a serious and potentially life-threatening complication of diabetes that occurs when the body produces high levels of ketones (indicates your body is burning fat for energy instead of glucose) due to a lack of insulin. It’s characterized by high BG, low blood pH (acidic blood), and the presence of ketones in the blood or urine. DKA is a medical emergency requiring immediate treatment) and when to seek emergency treatment. RN #10 documented Patient #5 declined to go to the emergency department, but failed to document she informed Patient #5’s physician of his BG outside of the ordered parameter; -on 4/9/25, during the 1:03 p.m. to 1:18 p.m. SN visit, RN #9 documented Patient #5’s BG was 371. RN #9 failed to document she informed Patient #5’s physician of Patient #5’s BG level outside of the ordered parameter; -on 4/12/24, during the 9:00 a.m. to 9:32 a.m. SN visit, license practical nurse (LPN) #13 documented Patient #5’s BG was 453 and she informed RN #9 about Patient #5’s elevated blood glucose. LPN #13 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/16/25, during the 9:12 a.m. to 9:33 a.m. SN visit, RN #11 documented Patient #5’s BG was 397. RN #11 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/17/25, during the 9:12 a.m. to 9:32 a.m. SN visit, RN #11 documented Patient #5’s BG was 420. RN #11 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/19/25, during the 9:23 a.m. to 9:37 a.m. SN visit, LPN #13 documented Patient #5’s BG was 522. LPN #13 documented she informed RN #9 of Patient #5’s 522 BG. RN #9 informed LPN #13 he would inform Patient #5’s physician on 4/21/25 of Patient #5’s BG outside of ordered parameters. LPN #13 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/20/25, during the 9:00 a.m. to 9:45 a.m. SN visit, RN #14 documented Patient #5’s BG was 356. RN #14 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/20/25, during the 1:00 p.m. to 1:25 p.m. SN visit, RN #15 documented Patient #5’s blood glucose was 378. RN #15 failed to document she informed Patient #5’s physician of his blood glucose outside of the ordered parameters; -on 4/22/25 during the 9:30 a.m. to 10:30 a.m. SN visit, RN #10 documented Patient #5’s BG was 357. RN #10 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/23/25, during the 8:40 a.m. to 9:15 a.m. SN visit, RN #9 documented Patient #5’s BG was 402. RN #9 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/24/25, during the 8:53 a.m. to 9:12 a.m. SN visit, RN #9 documented Patient #5’s BG was 388. RN #9 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/26/25, during the 8:56 a.m. to 9:19 a.m. SN visit, LPN #13 documented Patient #5’s BG was 392. LPN #13 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/27/25, during the 9:47 a.m. to 11:55 a.m. SN visit, LPN#13 documented Patient #5’s BG was 446. LPN #13 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; -on 4/28/25, during the 8:48 a.m. to 9:13 a.m. SN visit, RN #9 documented Patient #5’s BG was 372 and on the BG log in Patient #5’s home RN #9 documented Patient #5’s BG, during this same SN visit, was 412 (Cross Reference G716). RN #9 failed to document he contacted Patient #5’s physician on either the SN visit or the home BG log for Patient #5’s BG outside of ordered parameters; -on 4/29/25, during the 9:00 a.m. to 9:15 a.m. SN visit, RN #9 documented Patient #5’s BG was 390. RN #9 failed to document she informed Patient #5’s physician of his BG outside of the ordered parameters; and -on 5/1/25, during the 8:46 a.m. to 9:04 a.m. SN visit and during the 5/2/25 8:49 a.m. to 9:09 a.m. SN visit, RN #9 documented Patient #5’s BG was 357. RN #9 failed to document he informed Patient #5’s physician of his BG outside of the ordered parameters. During a home visit on 5/6/25 at 4:46 p.m., the surveyor observed Patient #5 taking his own BG level. Patient #5 stated during his SN visits he took his own BG level and the SN providing his visit documented his BG level on his home log and administered his two types of insulin as ordered based on his BG level. During a home visit on 5/6/25 at 5:05 p.m., RN #10 confirmed she was scheduled to provide Patient#5 care Tuesday and Friday evenings. RN #10 stated she also occasionally covered other SN visits for Patient #5. RN #10 stated RN #9 was Patient #5’s RN case manager and he coordinated with the team of SNs who provided Patient #5 care using a text messaging application. RN #10 stated anytime RN#9 received new orders for Patient #5, RN #9 would communicate those changes via the text messaging application and he would write a new care plan order for Patient #5. RN #10 stated she also reviewed Patient #5’s orders to know what medications to administer and when to notify Patient #5’s physician if Patient #5’s BG was elevated. RN #10 stated she was aware she was to contact Patient #5’s physician if his BG was greater than 400. RN #10 stated she was unaware Patient #5 also had an order which stated the SN should inform Patient #5’s physician if Patient #5’s BG was less than 60 or over 350, thus, she did not think to contact Patient #5’s physician on 4/22/25 when his BG was 357. RN #5 stated on 4/8/25, when Patient #5’s BG was 464 she remembered educating Patient #5 on DKA signs and symptoms and advising him to go to the nearest emergency room, but he declined to be seen in the emergency room. RN #10 stated she thought she also informed Patient #5’s physician of his elevated BG, but acknowledged she failed to document contacting Patient #5’s physician. On 5/7/25 at 11:40 a.m., the surveyor attempted to interview LPN #13, but was unable to speak with LPN #13 prior to the survey exit. During an interview 5/7/25 at 12:14 p.m., RN #11 acknowledged she occasionally provided SN visits to Patient #5. RN #11 stated RN #9 was Patient #5’s RN case manager and he coordinated with the team of SN who provided Patient #5 care using a text messaging application. RN #11 stated anytime RN#9 received new orders for Patient #5, RN #9 would communicate those changes via the text messaging application and he would write a new care plan order for Patient #5. RN #11 stated she also reviewed the written instructions in Patient #5’s home to know how much insulin to provide Patient #5. RN #11 stated per her recollection of Patient #5’s orders, she was to inform Patient #5’s physician if his BG was greater than 350. RN #11 could not remember if she had contacted Patient #5’s physician during the three times she documented his BG was greater than 350. RN #11 stated if she did notify the physician she would have documented this in the care management section of her visit note. During an interview on 5/7/25 at 12:18 p.m., RN #15 confirmed she occasionally provided SN visits to Patient #5. RN #15 stated she recalled Patient #5’s BG parameters were to call his physician if his BG was under 50 or over 400. RN #15 stated she also used symptoms to decide if she would notify a physician regarding a patient’s BG outside of ordered parameters. During an interview on 5/7/25 at 10:31 a.m., RN #9 stated Patient #5 was referred to home health care services on 1/15/25 as he required education on how to inject Trulicity and to try teach Patient #5 how to fill and use a medication planner. RN #9 stated at Patient #5’s start of care, RN #9 attempted to obtain a BG parameter on when to notify Patient #5’s physician, but Patient #5’s physician declined to provide a BG parameter to RN #9. RN #9 stated Patient #5’s physician told RN #9 he was not concerned about Patient #5’s BG levels greater than 600. RN #9 stated Patient #5’s physician ordered RN #9 to assist Patient #5 with learning how to inject Trulicity and to improve Patient #5’s compliance with medication management. RN #9 stated Patient #5’s physician requested to reexamine Patient #5 in mid-February 2025 to reevaluate the effectiveness of Trulicity and metformin medications on lowering Patient #5’s BG. RN #9 acknowledged he failed to document this conversation with Patient #5’s physician in Patient #5’s record. During continued interview, RN #9 stated when Patient #5 returned home from the hospital on 3/21/25, the discharge paperwork indicated Patient #5 was to begin taking insulin lispro (Humalog). RN #9 stated the instructions for the sliding scale, for Patient #5’s Humalog, included to administer 12 units of Humalog and to call Patient #5’s physician if Patient #5’s BG was greater than 400. RN #9 acknowledged he also documented a BG parameter to call Patient #5’s physician if Patient #5’s BG was less than 60 or over 350. RN #9 stated the parameter to call Patient #5’s physician if his BG was less than 60 or over 350 was mistakenly added to Patient #5’s POC orders. RN #9 stated this was a standing order the agency used if a physician did not provide a BG parameter. RN #9 stated the order to call Patient #5’s physician if his BG was over 400 was the accurate parameter for Patient #5. RN #9 stated he obtained this order from Patient #5’s 3/21/25 hospital discharge paperwork and confirmed this order with Patient #5’s physician in a verbal order during his 3/22/25 resumption of care assessment visit. Cross Reference G708 During continued interview, RN #9 stated anytime Patient #5’s BG was over 400 he communicated this to Patient #5’s physician. RN #9 stated the SNs who took care of Patient #5 on the weekend would inform RN #9 when Patient #5 BG was over 400; and RN #9 would call Patient #5’s physician on Monday to inform the physician of the elevated BG levels over the weekend. RN #9 stated he instructed the SNs covering Patient #5’s weekend visits to inform RN #9 about any elevated BG levels versus calling Patient #5’s physician as the SN working on the weekend would be put in contact with an on-call physician who may not be familiar with Patient #5. RN #9 stated Patient #5’s BG was often elevated, thus, it was not urgent to let Patient #5’s physician know about Patient #5’s elevated BG compared to a patient who typically did not have elevated BG. RN #9 stated anytime he observed or another SN informed him Patient #5 had an elevated BG over 400 he always let Patient #5’s physician know, but acknowledged he failed to document in Patient #5’s record each time he informed Patient #5’s physician of Patient #5’s BG outside of ordered parameters. During an interview on 5/7/25 at 2:03 p.m., the ADON reviewed Patient #5’s POCs and supplemental orders and acknowledged Patient #5’s orders failed to have accurate BG parameters listed on when to notify Patient #5’s physician. The ADON reviewed Patient #5’s 3/22/25 supplemental orders and acknowledged Patient #5 had two conflicting BG parameters: to call if his BG was less than 60 or over 350 and to call if Patient #5’s BG was over 400. The ADON stated the order to call Patient #5’s physician if his BG was under 60 or over 350 was a generic care plan order agency SNs could add to a patient’s POC. The ADON stated RN #9 should have modified this order to say call Patient #5’s physician if his BG was less than 60 or over 400. The ADON stated based on the orders, SNs should have called Patient #5’s physician any time his blood glucose was less than 60 or over 350. The ADON reviewed Patient #5’s SN notes with the surveyor and acknowledged Patient #5 had 18 visits where an agency SN documented a BG over 350 and failed to document they informed Patient #5’s physician. The ADON stated all SNs, regardless if they were an LPN or RN, and regardless of the day of the week they provided Patient #5 care, should have called Patient #5’s physician when the SN observed Patient #5 to have a BG greater than 350. The ADON stated she was pleased with the care coordination that occurred between the LPN and RNs when they notified RN #9 of Patient #5’s elevated BG, but she was disappointed the SNs had not also called and documented they called Patient #5’s physician themselves. The ADON stated she would review parameters with all agency SNs to ensure compliance with this regulation. 2. Similar findings of the agency failing to ensure patients received care as ordered was found for Patient #2 (failed to provide SN visits as ordered); Patient #8 (failed to provide suprapubic catheter changes with the size of catheter as ordered and the frequency as ordered); and Patient #9 (failed to provide SN visits as ordered).”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure each patient’s plan of care (POC) was reviewed by the physician at least every 60 days for 2 of 4 patients records reviewed who were on services longer than 60 days (Patients #4 and #8). Findings include: 1. The clinical record for Patient #8 was reviewed on 5/6/25. The POC for the certification period dated 2/19/25 to 4/19/25 revealed a start of care date of 6/30/23; diagnosis included: neuromuscular dysfunction of bladder, stage 4 pressure ulcer of left buttocks; encounter for fitting and adjustment of urinary device, encounter for attention to cystostomy, rhabdomyolysis, asthma, other stimulant abuse, major depressive disorder, post-traumatic stress disorder, unspecified injury at T7-T10 level of thoracic spinal cord, assault by pushing from high place, epilepsy, viral hepatitis C, and dependence on wheelchair. POC orders included: skilled nursing (SN) visits two times a week for one week, three times a week for eight weeks and one as needed (PRN) visit for assessment; wound care; suprapubic catheter (a tube inserted, through a surgical incision made in a person’s abdomen, into a person’s bladder used to drain urine) changes; depression screening, and patient education on medications, disease process, pressure ulcer prevention, safety and fall risk. The POC for the certification period dated 4/20/25 to 6/18/25 revealed a start of care date of 6/30/23; diagnosis included: neuromuscular dysfunction of bladder, stage 4 pressure ulcer of left buttocks; encounter for fitting and adjustment of urinary device, encounter for attention to cystostomy, rhabdomyolysis, asthma, other stimulant abuse, major depressive disorder, post-traumatic stress disorder, unspecified injury at T7-T10 level of thoracic spinal cord, assault by pushing from high place, epilepsy, viral hepatitis C, and dependence on wheelchair. POC orders included: skilled nursing (SN) visits three times a week for nine weeks for assessment; wound care; suprapubic catheter (a tube inserted, through a surgical incision made in a person’s abdomen, into a person’s bladder used to drain urine) changes; depression screening; and patient education on medications, disease process, pressure ulcer prevention, safety and fall risk. a) Clinical record review showed the POC was not reviewed and approved by the physician at least every 60 days. Review of Patient #8’s POCs for the certification periods dated 2/19/25 to 4/19/25 and 4/20/25 to 6/19/25, revealed the physician had not reviewed and signed the POCs. 2. Similar finding of the agency failing to ensure a physician reviewed each patient’s POC every 60 days was found for Patient #4. 3. During an interview on 5/7/25 at 4:33 p.m., the medical records coordinator stated she was responsible for faxing patient’s POCs and supplemental orders to physicians for review. The medical records coordinator stated the agency’s quality assurance (QA) registered nurse (RN), RN #12, would complete her QA review of a patient’s POC and then alert the medical records coordinator when the POC was ready to be sent to the patient’s physician for review. The medical records coordinator stated she struggled at times to get POCs back from physicians in a timely manner. The medical records coordinator stated she would keep track of how many times she faxed a POC to a physician, but once she received the POC back signed she shredded the documentation of her attempts. The medical records coordinator stated she did not have an official system showing how she kept track of what documents she sent to physicians to review and sign. During continued interview, the medical records coordinator stated she had first sent Patient #4’s POC, for the certification period dated 1/26/25 to 3/26/25, to his physician for review on 3/6/25, but acknowledged she failed to have documentation showing she had faxed the POC on this date. The medical records coordinator acknowledged as of 5/7/25 she had failed to send Patient #8’s two POCs to her physician for review and she could not provide an answer why she had failed to send the POCs to the physician for review. During an interview on 5/7/25 at 4:33 p.m., the assistant director of nursing (ADON) stated she was familiar with the regulation to have physicians review patient’s POCs every 60 days. The ADON stated the medical records coordinator was relatively new to her position. The ADON stated the medical records coordinator’s lack of a tracking system and failure to maintain documented evidence of when she faxed POCs to physicians for review contributed to the agency’s failure of ensuring physicians reviewed and signed patient’s POCs every 60 days. The ADON stated she would work with the medical records coordinator to develop a tracking system which included maintenance of all documentation showing the agency’s attempts to have physicians review and sign a patient’s POC to improve compliance with this regulation.”

“Development and evaluation of plan of care CFR(s): 484.75(b)(2) Development and evaluation of the plan of care in partnership with the patient, representative (if any), and caregiver(s); This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure the skilled nurse (SN) developed an accurate patient plan of care (POC) in partnership with the patient and the patient’s physician in 2 of 9 active records reviewed (Patients #4 and #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 5/5/25. The POC for the certification period dated 1/15/25 to 3/15/25, signed by Patient #5’s physician on 2/27/25, revealed a start of care date of 1/15/25; diagnosis included: Type 2 diabetes mellitus with hyperglycemia, hypertension, hyperlipidemia, atherosclerotic heart disease, tobacco use, long-term use of injectable non-insulin antidiabetic medication, long-term use of oral hypoglycemic medication, and long-term use of antithrombotics/antiplatelets. Plan of care orders included skilled nurse (SN) visits one time a week for nine weeks and five as needed (PRN) visits for the following: assessment; medication education and management including use, dose, frequency, side effects and when to call MD [medical doctor]/911; patient/caregiver assessment and education on diabetic foot care, fall risk, on administering Trulicity injectable medication (diabetes medication for adults that helps a body release its own insulin and can help improve a patient’s blood glucose (BG)), proper disposal of sharps, on correct use of a medication planner, on expressing satisfaction/dissatisfaction of pain regimen and follow up with MD, and on use of both prescriptive and non-prescriptive pain medication; and SN to fill medication planner (no frequency provided). The POC for the certification period dated 3/16/25 to 5/14/25, signed by Patient #5’s physician on 4/24/25, revealed a start of care date of 1/15/25; diagnosis included: Type 2 diabetes mellitus with hyperglycemia, hypertension, hyperlipidemia, atherosclerotic heart disease, tobacco use, long-term use of injectable non-insulin antidiabetic medication, long-term use of oral hypoglycemic medication, and long-term use of antithrombotics/antiplatelets. Plan of care orders included SN visits one time a week for three weeks for the following: assessment; medication education and management including use, dose, frequency, side effects and when to call MD/911; patient/caregiver assessment and education on diabetic foot care, on fall risk, on administering insulin injectable medication, proper disposal of sharps, on correct use of medication planner, on expressing satisfaction/dissatisfaction of pain regimen and follow up with MD, and on use of both prescriptive and non-prescriptive pain medication; and SN to fill medication planner (no frequency provided). Further review of the POCs for the certification periods dated 1/15/25 to 3/15/25 and 3/16/25 to 5/14/25 revealed Patient #5 was prescribed the following medications: -Abilify, two milligrams (mg), take one tablet by mouth daily; -Gabapentin, 800 mg, take one tablet by mouth three times a day; -Lipitor, 80 mg, take one tablet by mouth daily -metformin HCI, 1000 mg, take one tablet by mouth twice a day; -Plavix, 75 mg, take one tablet by mouth daily; -Protonix, 20 mg, take one tablet by mouth daily; -Trazodone HCI, 50 mg, take one tablet by mouth daily; and -Trulicity subcutaneous solution pen-injector, 1.5 mg/0.5 milliliters (ml), inject one unit subcutaneously once per week. Review of a 3/28/25 supplemental order, written by the assistant director of nursing (ADON), signed on 3/28/25 by Patient #5’s physician, showed Patient #5’s SN visits were to increase to three times a day to assist him with administration of insulin. a) Clinical record review revealed the agency failed to ensure the SN included a complete and accurate medication list for Patient #5. Review of Patient #5’s medication list from his referral paperwork, sent to the agency on 1/13/25, revealed as of a 1/6/25 physician visit, Patient #5 was to take the following medications: -Abilify, two mg, take one tablet by mouth daily; -Gabapentin, 800 mg, take one tablet by mouth three times a day; -Lipitor, 80 mg, take one tablet by mouth daily; -metformin HCI, 1000 mg, take one tablet by mouth twice a day; -Plavix, 75 mg, take one tablet by mouth daily; -Protonix, 20 mg, take one tablet by mouth daily; -Trazodone HCI, 50 mg, take one tablet by mouth daily; -Trulicity subcutaneous solution pen-injector, 1.5 mg/0.5 ml, inject one unit subcutaneously once per week; -Farxiga, 10 mg, take one tablet by mouth each morning; -lisinopril, 20 mg, take one tablet by mouth each day; -Vitamin D2 1,250 micrograms (mcg) (50,000 unit) -no dosage prescribed; and -fish oil -no dosage prescribed. Review of Patient #5’s POCS for certification periods dated 1/15/25 to 3/15/25 and 3/16/25 to 5/14/25 failed to show all medications prescribed to Patient #5 including the Farxiga, lisinopril, Vitamin D2 and fish oil. During a home visit on 5/6/26 at 4:46 p.m., Patient #5 stated he was not sure of all the medications he took. Patient #5 stated registered nurse (RN) #9 was responsible for ordering his medications and setting up Patient #5’s medication planner weekly. Patient #5 stated he took his medications daily as they were distributed in his medication minder and the SN who came to administer his insulin three times a day also reminded him to take his oral medications during their visits. During an interview on 5/7/25 at 10:31 a.m., RN #9 stated when he completed a start of care assessment visit, especially for a patient who would require medication education and medication set-up, RN #9 would review the patient’s referral paperwork to determine what medications to fill the patient’s medication planner with and how to educate the patient to take the medications. RN #9 stated he followed this process to determine Patient #5’s medication list. RN #9 stated at Patient #5’s start of care visit, Patient #5 declined to take over the counter supplements and RN #9 informed Patient #5’s physician of Patient #5’s decision to not take fish oil or Vitamin D2. RN #9 acknowledged he failed to document this conversation in Patient #5’s record. RN #9 stated he must have missed Patient #5’s physician ordered Farxiga on Patient #5’s referral documentation. RN #9 stated he recalled Patient #5’s physician specifically discussed with RN #9 to educate Patient #5 on how to use metformin and Trulicity to manage Patient #5’s BG. RN #9 stated Patient #5’s physician did not verbally instruct him on also having Patient #5 use Farxiga to assist Patient #5 with managing his BG. Review of a 3/21/25 hospital discharge referral paperwork, revealed Patient #5 was to stop injecting Trulicity 3 mg/0.5 ml once per week and to take the following medications: -Abilify, two mg, take one tablet by mouth daily; -Gabapentin, 800 mg, take one tablet by mouth three times a day; -Lipitor, 80 mg, take one tablet by mouth daily -metformin HCI, 1000 mg, take one tablet by mouth twice a day; -Plavix, 75 mg, take one tablet by mouth daily; -Protonix, 20 mg, take one tablet by mouth daily; -Trazodone HCI, 50 mg, take one tablet by mouth daily; -famotidine, 20 mg, take one tablet by mouth daily; -fluticasone propionate, 50 mcg/actuation, two nasal sprays daily as needed; -glipizide, 10 mg, take one tablet by mouth daily; -amoxicillin-clavulanate (Augmentin), 875-125 mg, take one tablet by mouth twice a day with meals for 14 days; -insulin glargine (brand name -Lantus Solostar) 100 unit/ml (3 ml), inject 15 units into the skin daily and 10 units nightly at bedtime; -insulin lispro, (brand name - Humalog) 100 unit/ml pen injection, provide for uncontrolled diabetes mellitus type 2, inject three times daily before meals and at bedtime as follows:- BG: 70 to 150 give zero units; 151-200 give two units; 201 to 250 give four units; 251-300 give six units; 301-350 give eight units; 351-400 give 10 units and over 400 give 12 units and call physician; -polyethylene glycol packet, 17 grams (g), take by mouth daily mixed in with four to eight ounces of water as needed for constipation; -senna-docusate, 8.6 -50 mg, take two tables by mouth two times daily for constipation; -lisinopril, 20 mg, take one tablet by mouth daily; and -oxycodone, 15 mg immediate release tablet, take one tablet by mouth every eight hours as needed for acute pain. Review Patient #5’s 3/22/25 supplemental orders, written by RN #9, showed Patient #5 was to stop his once a week Trulicity injection and was to add the following medications: -insulin lispro subcutaneous solution pen-injector, 100 unit/ml, 15 units injected subcutaneously daily in the morning; -insulin lispro subcutaneous solution pen-injector, 100 unit/ml, 10 units injected subcutaneously daily in the evening; -insulin glargine Solostar, 100 unit/ml pen injection, provide for uncontrolled diabetes mellitus type 2, three times a day as follows:- BG: 70 to 150 give zero units; 151-200 give two units; 201 to 250 give four units; 251-300 give six units; 301-350 give eight units; 351-400 give 10 units and over 400 give 12 units and call physician; -Augmentin, 500 - 125 mg, take one tablet twice a day by mouth ending on 4/5/25; - Glucotrol XL (generic name - glipizide) extended release 24 hour, 10 mg, take one tablet by mouth with a note stating Patient #5’s insurance would not cover this medication: and -oxycodone HCI, 15 mg, take one tablet as needed by mouth every eight hours for pain. Further review of Patient #5’s 3/22/25 supplemental orders showed RN #9 wrote the orders for insulin lispro as insulin glargine and insulin glargine as insulin lispro. Additionally, the supplemental orders failed to show Patient #5 was to take famotidine, fluticasone propionate, lisinopril, polyethylene glycol and senna-docusate. During a home visit on 5/6/25 at 5:05 p.m., RN #10 confirmed she was scheduled to provide Patient #5 care Tuesday and Friday evenings and occasionally she filled in for other SNs who were scheduled to see Patient #5 during his three shifts a day. RN #10 stated she assisted Patient #5 with determining how much insulin lispro to provide Patient #5 based on his BG; and prior to 4/30/25, she would also administer Patient #5’s evening insulin glargine dose. RN #10 stated RN #9 was Patient #5’s RN case manager, completed all of Patient #5’s assessments and filled Patient #5’s weekly medication planner. RN #10 stated when she started to provide Patient #5 care, she reviewed his orders to know how much insulin glargine and lispro to provide Patient #5. RN #10 stated she noted RN #9 had mistakenly documented insulin glargine as insulin lispro and vice versa, but acknowledged she failed to inform RN #9 or agency management of this mistake. During an interview on 5/7/25 at 12:14 p.m., RN #11 confirmed she occasionally provided SN visits to Patient #5. RN #11 stated she knew how much of each type of insulin to provide Patient #5 at her visits based on information communicated to her from RN #9 via a text messaging application used by the agency and by the information written down by RN #9 for Patient #5 in Patient #5’s home. RN #11 confirmed she failed to review Patient #5’s POC orders so she did not notice RN #9 had mistakenly written orders for insulin glargine as insulin lispro and vice versa. During an interview on 5/7/25 at 10:31 a.m., RN #9 acknowledged he mistakenly documented the orders for Patient #5’s insulin glargine as insulin lispro and vice versa. RN #9 stated when Patient #5 returned from the hospital on 3/22/25, RN #9 knew Patient #5 was prescribed Lantus (insulin glargine) two times a day and Humalog (insulin lispro) to be administered three times a day using a sliding scale. RN #9 stated he communicated this order to all SNs who provided care to Patient #5 and was confident all agency SNs provided Patient #5 with his two types of insulin accurately. RN #9 acknowledged he failed to document these medications accurately. RN #9 stated he was less familiar with the generic names of insulin and he would ensure to pay more attention in the future to the generic names so he does not make this mistake again. During continued interview, RN #9 stated when Patient #5 returned from the hospital, RN #9 noted Patient #5 had insulin glargine and lispro added along with glipizide, famotidine and fluticasone propionate. RN #9 stated he reviewed all the ordered medications with Patient #5. RN #9 stated Patient #5 informed RN #9 he declined to take the famotidine and fluticasone propionate, and Patient #5’s insurance carrier refused to pay for glipizide. RN #9 stated after he discussed the medications ordered from the hospital with Patient #5, RN #9 confirmed the medication orders from the hospital along with Patient #5’s decision on which medications he agreed to take with Patient #5’s physician. RN #9 stated he wrote the supplemental orders to reflect the medications Patient #5 agreed to take. RN #9 acknowledged he failed to document Patient #5 declined to take some of the medications ordered from the hospital; and RN #9 failed to document he coordinated Patient #5’s choices with Patient #5’s physician. Review of a 4/29/25 physician visit, received by the agency on 4/29/25 at 8:57 p.m. via fax, showed Patient #5’s physician ordered Patient #5 to receive 25 units of insulin glargine (Lantus) once daily versus 15 units in the morning and 10 units in the evening. Additionally, Patient #5’s physician ordered the agency to increase the insulin glargine by two units every other day until Patient #5 reached a maximum of 50 units a day or his fasting morning BG was under 150. Patient #5 was to start taking 10 mg of Farxiga once a day and to continue insulin lispro (Humalog) three times a day using the sliding scale as previously ordered. Review of a 4/30/25 supplemental order, written by RN #9, showed Patient #5 was to stop receiving insulin lispro 10 units at night and to receive 10 mg of Farxiga once a day by mouth. During a home visit on 5/6/25, the surveyor observed a hand written BG log which showed 25 units of Lantus (insulin glargine) was to be administered each day and increased by 2 units every other day. During an interview on 5/7/25 at 10:31 a.m., RN #9 stated he was present during Patient #5’s 4/29/25 doctors visit as the visit occurred via telehealth. RN #9 stated he was informed by Patient #5’s physician to combine the 15 units of Lantus administered each morning and 10 units of Lantus administered at night into one dose of 25 units each morning. Additionally, due to Patient #5’s continued high BG each morning, Patient #5 was to receive two additional units of Lantus every other day until Patient #5 had a fasting BG of under 150 in the morning or reached a maximal dosage of 50 units of Lantus. RN #9 stated he communicated this order to the other agency SNs via the text messaging application the agency used, and he documented this change on Patient #5’s home BG log, but acknowledged he failed to write this order accurately. RN #9 acknowledged he continued to confuse insulin glargine with insulin lispro when he wrote the 4/30/25 supplemental order, and he should have written the order to say stop administering 10 units of insulin glargine at night. Additionally, RN #9 stated the order should have stated to administer 25 units of Lantus each morning and to increase two units of Lantus every other day until Patient #5 achieved a fasting morning BG of under 150 or Patient #5 reached a maximal dosage of 50 units of Lantus. During an interview on 5/7/25 at 4:12 p.m., RN #12 confirmed she was the RN who completed quality assurance (QA) checks for the agency. RN #12 stated she reviewed start of care and recertification assessments, medication lists, care plan and supplemental orders documented by the clinicians for accuracy. RN #12 stated if she noted a mistake on any of these documents during her review, she would alert the clinician of the mistake and request the clinician correct the mistake. RN #12 stated once she received the correction(s) she would utilize the information from the assessment, medication list, care plan and supplemental orders to create a patient’s POC. RN #12 stated she did not review medication lists sent by referring physicians or the hospital. RN #12 stated she was not aware RN #9 had failed to add medications ordered for Patient #5 to his medication list. RN #12 stated she did review the order written by RN #9 in which he mistakenly wrote orders for insulin glargine as orders for insulin lispro and vice versa and she must have missed this mistake. During an interview on 5/7/25 at 2:03 p.m., the ADON reviewed Patient #5’s referral documentation, the 3/21/25 hospital documentation, and the 4/29/25 physician office documentation sent to the agency. The ADON acknowledged Patient #5’s POCs with the certification periods dated 1/15/25 to 3/14/25, 3/16/25 to 5/14/25 and supplemental orders failed to have all medications ordered for Patient #5 accurately listed. The ADON stated the agency expected a SN to review referral, hospitalization, and/or physician documentation with a patient to accurately generate a medication list for a patient. The ADON stated if a patient declined to take an ordered medication, the agency expected the clinician completing the assessment to inform the ordering physician of the patient’s refusal to take the ordered medication and to document the patient’s refusal in the patient’s medical record. During continued interview, the ADON reviewed the 3/22/25 supplemental orders and acknowledged RN #9 mistakenly documented orders for insulin glargine as insulin lispro and vice versa. The ADON acknowledged the other SNs who worked with Patient #5 failed to inform the agency of this mistake and the agency QA nurse, RN #12, also failed to catch this mistake. The ADON also acknowledged RN #9 continued to mistake insulin lispro for insulin glargine when he wrote his incomplete order on 4/30/25 to reflect the changes the agency received from Patient #5’s physician for modifying Patient #5’s insulin glargine dosage. The ADON stated RN #9 had informed her he confused the insulin glargine and insulin lispro as he was used to referring to these two medications by their brand names and not the generic names. The ADON stated she educated RN #9 he could refer to the medications by their brand names in his documentation in the future to try to reduce this documentation mistake. b) Clinical record review revealed the agency failed to ensure the SN obtained and documented accurate BG parameters on when to notify Patient #5’s physician. Review of the POC for the certification period dated 1/15/25 to 3/15/25 showed RN #9 documented Patient #5 was admitted to home health care post hospitalization from an episode of vertigo which was chronic for Patient #5. RN #9 documented Patient #5 recently moved into his own apartment and was struggling with controlling his BG. RN #9 documented Patient #5’s BG was greater than 600 (normal BG is 80-120) at his physician’s office on 1/14/25. RN #9 documented Patient #5 required supervision in medication management to gain stable BG levels and compliance with taking medication. The POC for the certification period dated 1/15/25 to 3/15/25 failed to reveal a BG parameters on when to notify Patient #5’s physician. Review of the POC for the certification period dated 3/16/25 to 5/14/25 failed to reveal a BG parameters on when to notify Patient #5’s physician. Review of a 3/17/25 transfer to inpatient facility assessment revealed Patient #5 was admitted to the hospital for an unknown reason. Review of a 3/22/25 resumption of care, after inpatient stay, assessment revealed RN #9 received a verbal order from Patient #5’s physician for medication and plan of care changes including wound care orders for his right toe amputation and orders for the addition of several new medications including insulin Glargine and insulin lispro. Review of an unsigned supplemental order, dated 3/17/25 to 5/14/25, revealed a treatment intervention, dated 3/22/25, showed SNs were to call Patient #5’s physician if his BG was less than 60 or greater than 350; and on 3/22/25 the medication insulin glargine Solostar was added with the precaution to call Patient #5’s physician if Patient #5’s BG was over 400. During an interview on 5/7/25 at 10:31 a.m., RN #9 stated Patient #5 was referred to home health care services on 1/15/25 as he required education on how to inject Trulicity and to try teach Patient #5 how to fill and use a medication planner. RN #9 stated at Patient #5’s start of care visit, RN #9 attempted to obtain a BG parameter on when to notify Patient #5’s physician, but Patient #5’s physician declined to provide a BG parameter to RN #9. RN #9 stated stated Patient #5’s physician told RN #9 he was not concerned about Patient #5’s BG levels greater than 600. RN #9 stated Patient #5’s physician ordered RN #9 to assist Patient #5 with learning how to inject Trulicity and to improve Patient #5’s compliance with medication management. RN #9 stated Patient #5’s physician requested to reexamine Patient #5 in mid-February 2025 to reevaluate the effectiveness of Trulicity and metformin on lowering Patient #5’s BG. RN #9 acknowledged he failed to document this conversation with Patient #5’s physician in Patient #5’s record. During continued interview, RN #9 stated when Patient #5 returned from the hospital on 3/22/25, the discharge paperwork indicated Patient#5 was to begin taking insulin lispro (Humalog). RN #9 stated the instructions for Patient #5’s Humalog sliding scale included to administer 12 units of Humalog and to call Patient #5’s physician if Patient #5’s BG was greater than 400. RN #9 acknowledged he also documented a BG parameter to call Patient #5’s physician if Patient #5’s BG was less than 60 or over 350. RN #9 stated the parameter to call Patient #5’s physician if his BG was less than 60 or over 350 was mistakenly added to Patient #5’s POC orders. RN #9 stated this was a standing order the agency used if a physician did not provide a BG parameter. RN #9 stated the order to call Patient #5’s physician if his BG was over 400 was the accurate parameter for Patient #5’s BG parameter. RN #9 stated he obtained this order from Patient #5’s 3/21/25 hospital discharge paperwork and confirmed this order with Patient #5’s physician in a verbal order during his 3/22/25 resumption of care assessment visit. During an interview on 5/7/25 at 2:03 p.m., the ADON reviewed Patient #5’s POCs and supplemental orders and acknowledged his POCs failed to have accurate blood glucose parameters listed on when to notify Patient #5’s physician. The ADON stated when the agency admitted a patient who required education on diabetic medication management, the agency expected the assessing SN to obtain a BG parameter from the patient’s physician. The ADON stated part of diabetic medication management was patient education on when to notify their physician of an abnormal BG level. The ADON stated if an agency SN was unable to obtain a BG parameter from a patient’s physician, the SN should document the conversation and the reason the physician declined to provide BG parameters. The ADON acknowledged RN #9 failed to document why Patient #5’s physician would not provide a BG parameter for Patient #5 at his 1/15/25 start of care assessment visit. During a continued interview, the ADON reviewed Patient #5’s 3/22/25 supplemental orders and acknowledged Patient #5 had two conflicting BG parameters: to call if Patient #5’s BG was less than 60 or over 350 and to call if Patient #5’s BG was over 400. The ADON stated the order to call Patient #5’s physician if his BG was under 60 or over 350 was a generic care plan order agency SNs could add to a patient’s POC. The ADON stated RN #9 should have modified this order to say call Patient #5’s physician if his BG was less than 60 or over 400. The ADON stated she would re-educate RN #9 to review his POC orders to ensure the POC contained accurate BG parameters. c) The agency failed to ensure the SN included a frequency for medication set-up on the POC orders. Review of POCS for the certification periods dated 1/15/25 to 3/15/25 and 3/16/25 to 5/14/25 showed a SN was to fill a medication planner as Patient #5 was unable to perform this task safely, had no family/friends willing/able to fill his medication planner, and Patient #5’s pharmacy did not provide this service. The POCs failed to show documentation of how often the SN was to fill Patient #5’s medication planner. During a home visit on 5/6/25 at 4:46 p.m, Patient #5 confirmed he received three SN visits daily from the agency from several different SNs. Patient #5 stated RN #9 was his primary SN. Patient #5 stated RN #9 was responsible for managing Patient #5’s medications including ordering refills and completing medication set-up for Patient #5’s once per week. Patient #5 stated RN #9 always ensured Patient #5 had two weeks worth of medication filled in two once a week medication planners to ensure Patient #5 was never without his medications. During an interview on 5/7/25 at 10:31 a.m., RN #9 confirmed he was Patient #5’s RN case manager. RN #9 stated he typically completed medication set-up for Patient #5 on Wednesdays and he always ensured Patient #5 had an extra week of medication set-up to ensure Patient #5 would not run out of medications in case a visit was missed for Patient #5. RN #9 acknowledged Patient #5’s POC orders failed to have a frequency listed for his medication set-up. RN#9 stated he did not think to include a frequency on the POC order for medication set-up as he knew to complete this task weekly. During an interview on 5/7/25 at 2:03 p.m., the ADON reviewed Patient #5’s POCS for the certification periods dated 1/15/25 to 3/15/25 and 3/16/25 to 5/14/25 and acknowledged the POCs were missing the frequency of when medication set-up was to occur. The ADON stated the agency expected SN to document the frequency for medication set-up to allow any SN in the agency to know what day and how often a patient should have medication set-up in case a regularly scheduled SN was unable to provide a patient care. The ADON stated during the POC for the certification period dated 1/15/25 to 3/15/25 the agency was primarily focused on attempting to teach Patient #5 how to fill his own medication planner, but acknowledged this POC had an order for medication set-up which failed to have documentation of the frequency this task was to be completed. 2. Similar findings of the agency failing to ensure the SN developed an accurate patient plan of care (POC) in partnership with the patient and the patient’s physician occurred for Patient #4. Specifically, the SN failed to remove a wound care order for a healed left foot wound on Patient #4’s POC for the certification period dated 1/26/25 to 3/26/25. 3. During an interview on 5/7/25 at approximately 2:45 p.m., the ADON acknowledged Patient #4 and #5 had mistakes on their POCs that were missed both by RN #9, other agency SNs and the QA nurse, RN #12. The ADON stated she and the assistant administrator had discussed how these mistakes were overlooked. The ADON stated she and the alternate administrator had begun to discuss ways to get a plan in place to ensure patient’s POCs were accurate in the future.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure skilled nurses (SNs) prepared accurate clinical documentation in 3 of 9 active patient records reviewed (Patients #4, #5 and #9). Findings include: 1. The clinical record for Patient #5 was reviewed on 5/5/25. The POC for the certification period dated 1/15/25 to 3/15/25, signed by Patient #5’s physician on 2/27/25, revealed a start of care date of 1/15/25; diagnosis included: type 2 diabetes mellitus with hyperglycemia, hypertension, hyperlipidemia, atherosclerotic heart disease, tobacco use, long-term use of injectable non-insulin antidiabetic medication, long-term use of oral hypoglycemic medication, and long-term use of antithrombotics/antiplatelets. Plan of care orders included SN visits one time a week for nine weeks and five as needed (PRN) visits for the following: assessment; medication education and management including use, dose, frequency, side effects and when to call MD [medical doctor]/911; patient/caregiver assessment and education on diabetic foot care, fall risk, on administering Trulicity injectable medication (diabetes medication for adults that helps a body release its own insulin and can help improve a patient’s blood glucose (BG)), proper disposal of sharps, on correct use of a medication planner, on expressing satisfaction/dissatisfaction of pain regimen and follow up with MD, and on use of both prescriptive and non-prescriptive pain medication; and SN to fill medication planner (no frequency provided). The POC for the certification period dated 3/16/25 to 5/14/25, signed by Patient #5’s physician on 4/24/25, revealed a start of care date of 1/15/25; diagnosis included: type 2 diabetes mellitus with hyperglycemia, hypertension, hyperlipidemia, atherosclerotic heart disease, tobacco use, long-term use of injectable non-insulin antidiabetic medication, long-term use of oral hypoglycemic medication, and long-term use of antithrombotics/antiplatelets. Plan of care orders included SN visits one time a week for three weeks for the following: assessment; medication education and management including use, dose, frequency, side effects and when to call MD/911; patient/caregiver assessment and education on diabetic foot care, on fall risk, on administering insulin injectable medication, proper disposal of sharps, on correct use of medication planner, on expressing satisfaction/dissatisfaction of pain regimen and follow up with MD, and on use of both prescriptive and non-prescriptive pain medication; and SN to fill medication planner (no frequency provided). Review of a 3/17/25 transfer to inpatient facility assessment revealed Patient #5 was admitted to the hospital for an unknown reason. Review of a 3/22/25 resumption of care, after inpatient stay, assessment revealed registered nurse (RN) #9 received a verbal order from Patient #5’s physician for medication and plan of care changes including wound care orders for his right toe amputation and orders for the addition of several new medications including insulin glargine (a long-acting type of insulin used to control high BG in people with diabetes - brand names include: Lantus, Basaglar, Toujeo, Semglee, Rezvoglar) and insulin lispro (a rapid-acting type of insulin used manage high BG in people with diabetes - brand names include: Humalog, Ademlog, Lyumjev). Review of a 3/21/25 hospital discharge referral paperwork revealed Patient #5 was to stop injecting Trulicity 3 milligrams (mg)/0.5 milliliters (ml) once per week and to take the following medications: -Abilify, two mg, take one tablet by mouth daily; -Gabapentin, 800 mg, take one tablet by mouth three times a day; -Lipitor, 80 mg, take one tablet by mouth daily; -metformin HCI, 1000 mg, take one tablet by mouth twice a day; -Plavix, 75 mg, take one tablet by mouth daily; -Protonix, 20 mg, take one tablet by mouth daily; -Trazodone HCI, 50 mg, take one tablet by mouth daily; -famotidine, 20 mg, take one tablet by mouth daily; -fluticasone propionate, 50 micrograms(mcg)/actuation, two nasal sprays daily as needed; -glipizide,10 mg, take one tablet by mouth daily; -amoxicillin-clavulanate (brand name - Augmentin), 875-125 mg, take one tablet by mouth twice a day with meals for 14 days; -insulin glargine (brand name - Lantus Solostar) 100 unit/ml (3 ml), inject 15 units into the skin daily and 10 units nightly at bedtime; -insulin lispro (brand name -Humalog), 100 unit/ml pen injection, provide for uncontrolled diabetes mellitus type 2, inject three times daily before meals and at bedtime as follows:- BG 70 to 150 give zero units; 151-200 give two units; 201 to 250 give four units; 251-300 give six units; 301-350 give eight units; 351-400 give 10 units and over 400 give 12 units and call physician; -polyethylene glycol packet, 17 grams (g), take by mouth daily mixed in with four to eight ounces of water as needed for constipation; -senna-docusate, 8.6 - 50 mg, take two tablets by mouth two times daily for constipation; -glipizide, 10 mg, take one tablet by mouth daily; -lisinopril, 20 mg, take one tablet by mouth daily; and -oxycodone, 15 mg immediate release tablet, take one tablet by mouth every eight hours as needed for acute pain. Review Patient #5’s 3/22/25 supplemental orders, written by RN #9, showed Patient #5 was to stop his once weekly Trulicity injections and was to add the following medications: -insulin lispro subcutaneous solution, pen-injector 100 unit/ml, 15 units daily injected subcutaneously in the morning; -insulin lispro subcutaneous solution, pen-injector 100 unit/ml, 10 units daily injected subcutaneously in the evening; -insulin glargine, 100 unit/ml pen injection, provide for uncontrolled diabetes mellitus type 2 three times a day as follows: BG 70 to 150 give zero units; 151-200 give two units; 201 to 250 give four units; 251-300 give six units; 301-350 give eight units; 351-400 give 10 units and over 400 give 12 units and call physician; -Augmentin, 500 - 125 mg, take one tablet twice a day by mouth ending on 4/5/25; - Glucotrol XL (generic name - glipizide) extended release 24 hour, 10 mg, take one tablet by mouth with a note stating Patient #5’s insurance would not cover this medication: and -oxycodone HCI, 15 mg, take one tablet as needed by mouth every eight hours for pain. Further review of Patient #5’s 3/22/25 supplemental orders showed RN #9 wrote the orders for insulin lispro as insulin glargine and insulin glargine as insulin lispro. Additionally the supplemental orders failed to show Patient #5 was to take famotidine, fluticasone propionate, lisinopril, polyethylene glycol and senna-docusate. Cross Reference G708 a) The agency failed to ensure the SN documented the accurate type of insulin administered to Patient #5. Review of SN notes from 4/4/25 through 5/4/25, completed by RN #9 showed RN #9 documented he administered Novolog (a type of insulin aspart, a fast-acting insulin used to manage high BG in people with diabetes) - a medication not prescribed for Patient #5 - 32 times. During a home visit on 5/6/26 at 4:46 p.m., Patient #5 stated he was not sure of all the medications he took, but he was positive he had never had the medicine Novolog administered by agency SNs. Patient #5 stated he received Lantus (insulin glargine) and Humalog (insulin lispro) injections from SNs three times a day. Patient #5 stated RN #9 was responsible for ordering his medications and setting up Patient #5’s medication planner weekly. Patient #5 stated he took his medications daily as they were distributed in his medication minder and the SNs who came to administer his insulin three times a day also reminded him to take his oral medications during their visits. During a home visit on 5/6/25 at 5:05 p.m., RN #10 confirmed she was scheduled to provide Patient #5 care Tuesday and Friday evenings and occasionally she filled in for other SNs who were scheduled to see Patient #5 during his three shifts a day. RN #10 stated she assisted Patient #5 with determining how much insulin lispro to provide Patient #5 based on his BG; and prior to 4/30/25, she would also administer Patient #5’s evening insulin glargine dose. RN #10 stated RN #9 was Patient #5’s RN case manager, completed all of Patient #5’s assessments and filled Patient #5’s weekly medication planner. RN #10 stated when she started to provide Patient #5 care, she reviewed his orders to know how much insulin glargine and lispro to provide Patient #5. RN #10 stated she noted RN #9 had mistakenly documented insulin glargine as insulin lispro and vice versa, but acknowledged she failed to inform RN #9 or agency management of this mistake. During the home visit, the surveyor observed Patient #5 take his BG and report to RN #10 his BG was 324. Patient #5 stated his BG was elevated as he was hungry and had eaten many carbohydrates on 5/6/25. The surveyor observed RN #10 confirm on Patient #5’s sliding scale she was to administer eight units of insulin lispro (Humalog). RN #10 stated Patient #5 had never had Novolog in the home and she showed the surveyor Patient #5’s insulin lispro pen prior to administering the six units left in one pen and administering another two units from a new insulin lispro pen, to provide Patient #5 with the eight ordered units of insulin lispro. During an interview on 5/7/25 at 10:31 a.m., RN #9 acknowledged he mistakenly documented the orders for Patient #5’s insulin glargine as insulin lispro and vice versa. RN #9 stated when Patient #5 returned from the hospital on 3/22/25, RN #9 knew Patient #5 was prescribed Lantus (insulin glargine) two times a day and Humalog (insulin lispro) to be administered three times a day using a sliding scale. RN #9 stated he communicated this order to all SNs who provided care to Patient #5 and was confident all agency SNs provided Patient #5 with his two types of insulin accurately. RN #9 acknowledged he failed to document these medications accurately on Patient #5’s supplemental orders. RN #9 stated he was less familiar with the generic names of insulin. RN #9 also stated he mistakenly documented he administered Novolog instead of Humalog to Patient #5. RN #9 stated he was familiar with the difference between Humalog and Novolog and he was not paying attention to the type of fast-acting insulin he documented he provided Patient #5. RN #9 stated he had never administered Novolog to Patient #5, only Lantus and Humalog. RN #9 stated he would ensure to pay more attention to his documentation to avoid making this mistake in the future. b) The agency failed to ensure SNs documented the accurate amount of insulin provided to Patient #5. Review of SN visit notes from 3/22/25 through 5/4/25 showed the following: -on 4/15/25, from 9:30 a.m. to 10:00 a.m., and on 4/25/25, from 4:00 p.m. to 5:00 p.m., RN #10 failed to document the amount and type of insulin she administered to Patient #5; -on 4/21/25, from 4:20 p.m. to 4:35 p.m., RN #9 documented he administered 100 units of Lantus, ten times the ordered amount, to Patient #5; -on 4/27/25, from 12:43 p.m. to 1:08 p.m., LPN #13 documented she administered Patient #5 six units of Humalog, but during a home visit on 5/6/25 the surveyor observed on Patient #5’s home BG log, during the midday shift, Patient #5 was given four units of Humalog; -on 4/29/25, from 9:00 a.m. to 9:15 a.m., RN #9 documented he administered Patient #5 12 units of Novolog (Cross Reference failure a) above), but during a home visit on 5/6/25 the surveyor observed on Patient #5’s home BG log, during the morning shift, Patient #5 was given 10 units of Humalog; -on 4/29/25, from 4:27 p.m. to 5:01 p.m., RN #9 documented he administered Patient #5 six units of Novolog (Cross Reference failure a) above), but during a home visit on 5/6/25 the surveyor observed on Patient #5’s home BG log during the evening shift, Patient #5 was given eight units of Humalog; -on 4/30/25, from 8:33 a.m. to 8:59 a.m., RN #9 documented he administered Patient #5 thirty seven units of Lantus, but during a home visit on 5/6/25 the surveyor observed on Patient #5’s home BG log, during the morning shift, Patient #5 was given 25 units of Lantus; and -on 5/1/25 from 8:46 a.m. to 9:04 a.m., RN #9 documented he administered Patient #5 ten thousand twenty seven units of Lantus, but during a home visit on 5/6/25 the surveyor observed on Patient #5’s home BG log, during the morning shift, Patient #5 was given 27 units of Lantus. During a home visit on 5/6/25 at 5:05 p.m., RN #10 confirmed she provided care to Patient #5 on 4/15/25 from 9:30 a.m. to 10:00 a.m. and on 4/25/25 from 4:00 p.m. to 5:00 p.m. RN #10 stated Patient #5 would take his own BG (surveyor observed this at the home visit) and she would record the BG on Patient #5’s home BG log as well as in his clinical record in the agency’s electronic medical record (EMR) system. RN #10 stated she would then use the sliding scale ordered for Patient #5’s Humalog to know how much insulin to administer for Patient #5 based on his BG. RN #10 also stated prior to 4/30/25 she would administer 15 units of Lantus during Patient #5’s morning visits and 10 units of Lantus during Patient #5’s evening visits. RN #10 stated she was positive she administered Lantus to Patient #5 both during his morning shift on 4/15/25 and his evening shift on 4/25/25, but acknowledged she failed to document this in Patient #5’s record in the agency’s EMR. RN #10 stated on 4/25/25 based on Patient #5’s BG of 120 she would not have administered any Humalog to Patient #5, but acknowledged she failed to document this on Patient #5’s record in his EMR as well as his home BG log. RN #10 stated the agency’s EMR had experienced some difficulties. RN #10 stated she always documented her visits, but the EMR was not always saving her visit notes. RN #10 stated she also sometimes clicked through her notes quickly and either of these issues might have caused Patient #5’s 4/15/25 clinical note to fail to have Patient #5’s BG documented and why her 4/15/25 and 4/25/25 visit notes failed to have what type and how much insulin she administered to Patient #5. RN #10 stated she understood the importance of accurate documentation and she would ensure to double check her clinical notes moving forward for accuracy to avoid this mistake in the future. On 5/7/25 at 11:40 a.m., the surveyor attempted to interview LPN #13, but was unable to speak with LPN #13 prior to the survey exit. During an interview on 5/7/25 at 10:31 a.m., RN #9 stated when he provided Patient #5 care, Patient #5 would take his BG and RN #9 would record this number on Patient #5’s home BG log as well as in a notebook. RN #9 stated prior to 4/30/25, he followed Patient #5’s orders and administered Patient #5 15 units of Lantus during his morning visit and 10 units of Lantus during his evening visits. RN #9 stated he also followed Patient #5’s sliding scale for Humalog and administered Patient #5 his Humalog as ordered on his sliding scale. RN #9 stated he would document Patient #5’s BG and the amount and type of insulin he administered Patient #5 immediately on Patient #5’s home BG log. RN #9 stated he would write Patient #5’s BG and the amount and type of insulin he provided Patient #5 during a visit on a notepad and when RN #9 had time, he would transcribe these numbers into the SN visit note for Patient #5. RN #9 stated any documentation on Patient #5’s home BG log was accurate. RN #9 acknowledged he mistakenly documented the amount and type of insulin he provided to Patient #5 on several SN notes in the agency’s EMR. c) The agency failed to ensure SNs accurately documented Patient #5’s BG level in his clinical record. Review of SN visit notes from 3/22/25 through 5/4/25 showed the following: -licensed practical nurse (LPN) #13 provided Patient #5 care from 5:35 p.m. to 5:50 p.m. and failed to document Patient #5’s BG; -RN #10 provided Patient #5 care on 4/15/25 from 9:30 a.m. to 10:00 a.m., and failed to document Patient #5’s BG; -LPN #13 provided Patient #5 care on 4/27/25 from 12:43 p.m. to 1:08 p.m., and documented Patient #5’s BG was 256, but the surveyor observed on a home BG log, Patient #5’s BG on 4/27/25 at his mid-day visit, was documented as 233; -RN #9 provided Patient #5 care on 4/28/25 from 8:48 a.m. to 9:13 a.m., and documented Patient #5’s BG was 372, but the surveyor observed on a home BG log, Patient #5’s BG on 4/28/25 at his morning visit, was documented as 412; and -RN #9 provided Patient #5 care on 4/29/25 from 4:27 p.m. to 5:01 p.m., and documented Patient #5’s BG was 347, but the surveyor observed on a home BG log, Patient #5’s BG on 4/29/25 at his evening visit, was documented as 314. During a home visit on 5/6/25 at 5:05 p.m., RN #10 confirmed she provided care to Patient #5 on 4/15/25 from 9:30 a.m. to 10:00 a.m. RN #10 stated Patient #5 would take his own BG (surveyor observed this at the home visit) and she would record the BG on Patient #5’s home BG log as well as in his clinical record in the agency’s EMR system. RN #10 stated the agency’s EMR had experienced some difficulties. RN #10 stated she always documented her visit, but the EMR was not always saving her SN notes. RN #10 stated she also sometimes clicked through her notes quickly and either of these issues might have caused Patient #5’s 4/15/25 clinical note to fail to have his BG documented. On 5/7/25 at 11:40 a.m., the surveyor attempted to interview LPN #13, but was unable to speak with LPN #13 prior to the survey exit. During an interview on 5/7/25 at 10:31 a.m., RN #9 stated when he provided Patient #5 care, Patient #5 would take his BG and RN #9 would record this number on Patient #5’s home BG log as well as in a notebook. RN #9 stated when he had a free moment, he then would enter Patient #5’s BG into the SN visit note for Patient #5 in the agency’s EMR. RN #9 stated the number on Patient #5’s home BG log was accurate for the 4/28/25 and 4/29/25 visits he provided Patient #5 from 8:48 a.m. to 9:13 a.m. and 4:27 p.m. to 5:01 p.m. respectively. RN #9 stated he must have accidently entered another patient’s BG into Patient #5’s 4/28/25 8:48 a.m. to 9:13 a.m. and 4/29/25 4:27 p.m. to 5:01 p.m. SN visit notes in the agency’s EMR. 2. Similar findings of the agency failing to ensure SNs prepared accurate clinical documentation was found for Patient #4 (SN #9 failed to document medication set-up and how Patient #4’s foley catheter was changed in March of 2025); and Patient #9 (SN #14 failed to document clarification she received on Patient #9’s medication list and SNs #9 and #14 documented certified nursing assistant (CNA) supervisory visits for Patient #9 with Patient #9 failing to have CNA visits). 3. During an interview on 5/7/25 at between 1:13 p.m. to 4:06 p.m., the assistant director of nursing (ADON) reviewed Patients #4, #5, and #9’s SN visit notes and acknowledged all three patient’s notes had errors in the SN’s clinical documentation. The ADON stated the agency had experienced difficulty with the agency’s EMR and she attributed some of the clinical notes failing to have accurate information documented in part due to this issue. The ADON also stated she had educated her staff to document in the agency EMR as soon as possible, and expected SN to document within 48 hours of when the visit occurred, to try to reduce documentation errors. The ADON stated she understood the importance of accurate clinical documentation and would re-educate all of her staff on reviewing their clinical notes for accuracy to reduce this deficient practice.”

“Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient’s discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient’s care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a discharge summary was sent to the primary care practitioner (PCP) within five business days of discharge for 3 of 4 discharged patients records reviewed (Patients #10, # 11 and # 12). Findings include: 1. The clinical record for Patient #12 was reviewed on 5/7/25. The plan of care (POC) for the certification period dated 11/7/24 to 1/5/25 revealed a start of care date of 11/7/25; diagnoses included muscle wasting and atrophy, Type 2 diabetes, neoplasm of uncertain behavior of brain, neoplasm of uncertain behavior of trachea, bronchus and lung, bipolar disorder, and hyperlipidemia. POC orders included physical therapy (PT) visits one to two every week for eight weeks for disease management, gait training, therapeutic exercise, pain management, endurance training, and patient/caregiver education. a. The agency failed to send Patient #12’s discharge summary to the physician within five business days of the patient’s discharge. Review of Patient #12’s clinical record revealed the patient was discharged from the agency on 12/10/24. Further review revealed the agency sent the discharge summary to Patient #12’s PCP on 1/17/25, thirty three days, after Patient #12 was discharged from the agency. During an interview on 5/7/25 at 3:05 p.m., the assistant director of nursing (ADON) stated the agency forgot to send out Patient #12’s discharge summary. The agency sent the discharge summary to the PCP office on 1/17/25. 2. Similar findings of the agency failing to send discharge summaries to a patient’s PCP within five days of the patient’s discharge from the agency was found for Patients #10 and #11.”