Golden Harmony Inc.

“Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This Standard is not met as evidenced by: Based on interview and record review the agency failed to ensure services were provided in accordance with physician’s orders for 1 of 3 active patients reviewed who received blood glucose monitoring and insulin administration (Patient #4). Findings include: AGENCY POLICY According to an undated agency policy titled, Physician Orders, (read in pertinent parts): “All medications, treatments and services provided to clients must be ordered by a physician. The agency communicates and integrates orders from all client physicians in the plan of care and assures coordination of all services and interventions provided to the client.” According to an undated agency policy titled, Skilled Nursing Services, (read in pertinent parts): “Skilled nursing services will be provided by a Registered Nurse or a Licensed Practical/Vocational Nurse under the supervision of a Registered Nurse and in accordance with a medically approved Plan of Care (physician’s orders).” 1. The clinical record for Patient #4 was reviewed on 1/2/24. The plans of care for the certification periods dated 9/8/23 to 11/6/23 and 11/7/23 to 1/5/24 revealed a start of care date of 5/21/21; diagnoses included type two diabetes, heart failure, diverticulosis, stage three chronic kidney disease, acute kidney failure, pulmonary embolism, rheumatoid arthritis, borderline personality disorder, depression, acute respiratory failure with hypoxia, angina, obesity, post-traumatic stress disorder, and pneumonia. Plan of care orders included skilled nurse (SN) visits two times a day for 60 days with three as needed (PRN) visits for assessment including vital signs, monitoring of blood glucose levels, administration of Lantus (a long acting insulin medication) and Humalog (a fast acting insulin medication), administration of Ozempic (a injectable medication used to reduce blood glucose levels in type two diabetics) once a week on Tuesdays, medication set-up, medication compliance, and monitoring of respiratory and cardiac status. Further review of the plans of care for the certification periods dated 9/8/23 to 11/6/23 and 11/7/23 to 1/5/24 revealed agency SNs were to notify Patient #4’s physician if Patient #4’s blood glucose (blood sugar) was below 70 milligrams/deciliter (mg/dl) or above 500 mg/dl. a) The agency failed to ensure Patient #4’s physician was notified when Patient #4’s blood glucose was below 70 mg/dl as ordered on Patient #4’s plan of care. Review of SN note on 11/5/23, for the morning visit, revealed registered nurse (RN) #6 documented Patient #4’s fasting blood sugar was 49 mg/dl. RN #6 documented Patient #4 ate cookies, cheese and drank some juice. RN #6 rechecked Patient #4’s blood glucose 15 minutes later and it registered 53 mg/dl. Patient #4 ate a bowl of cereal and drank more juice. RN #6 rechecked Patient #4’s blood glucose 15 minutes later and it registered 64 mg/dl. RN #6 documented Patient #4 reported she did not eat anything the night before and RN #6 educated Patient #4 on the importance of eating a snack before bed to prevent hypoglycemic (low blood glucose in a patient’s blood) episodes overnight. The11/5/23 morning SN note failed to show if RN #6 notified Patient #4’s physician of her blood glucose below 70 mg/dl as ordered on Patient #4’s plan of care. Review of a SN note on 11/20/23, for the morning visit, revealed the director of nursing (DON), who was also the administrator, documented Patient #4’s random blood glucose was 62 mg/dl. The DON documented Patient #4 ran out of her Humalog and her physician was notified of this on 11/17/23. The DON stated Patient #4 was not showing signs of symptoms of hyperglycemia (excessive amount of glucose circulating in a patient’s blood) and Patient #4 was educated on signs and symptoms of hypoglycemia. The 11/20/23 morning SN note failed to show the DON contacted Patient #4’s physician to inform the physician of Patient #4’s blood glucose below 70 mg/dl as ordered on Patient #4’s plan of care. Review of a SN note on 12/13/23, for the morning visit, revealed the DON documented Patient #4’s random blood glucose was 62 mg/dl. The DON documented Patient #4’s Humalog was held according to the sliding scale (located in her home only as no order was obtained - Cross Reference G580). The DON documented Patient #4 showed no signs of hypoglycemia/hypoglycemia and Patient #4 was educated on the signs and symptoms of hypoglycemia. The 12/13/23 morning SN note failed to show the DON contacted Patient #4’s physician to inform the physician of Patient #4’s blood glucose below 70 mg/dl as ordered on Patient #4’s plan of care. Review of a SN note on 12/17/23, for the morning visit, revealed RN #6 documented Patient #4’s fasting blood glucose was 46 mg/dl. RN #6 stated Patient #4’s father was in the hospital the previous night, and Patient #4 stayed with her father at the hospital. RN #6 documented Patient #4 reported she failed to eat the night before and her blood glucose was 46 mg/dl when she checked her blood glucose first thing the morning of 12/17/23. RN #6 documented Patient #4 informed her she drank a Pepsi prior to RN #6 arriving at Patient #4’s home and RN #6 documented Patient #4’s blood glucose was 54 mg/dl upon RN #6’s arrival. RN #6 documented she waited 15 minutes and rechecked Patient #4’s blood glucose and it registered 65 mg/dl. RN #6 documented she held Patient #4’s Humalog and instructed Patient #4 to eat a banana with eggs and toast. RN #6 documented Patient #4 was not showing signs or symptoms of hypoglycemia and RN #6 educated Patient #4 if she started to experience signs/symptoms of hypoglycemia to call the on-call nurse. The 12/17/23 morning SN note failed to show if RN #6 notified Patient #4’s physician of her blood glucose below 70 mg/dl as ordered on Patient #4’s plan of care. During an interview on 1/4/23 at 10:23 a.m., RN #6 confirmed she provided care to Patient #4 and was aware plan of care orders which instructed the SN to notify Patient #4’s physician if Patient #4’s blood glucose was below 70 mg/dl. RN #6 stated she could not recall if she notified Patient #4’s physician on 11/5/23 or 12/17/23 when Patient #4’s blood glucose was below 70 mg/dl during her morning visits. RN #6 stated she stayed with Patient #4 on both visits to ensure Patient #4’s blood glucose was trending upward. RN #6 stated she thought she would have notified Patient #4’s physician, especially if Patient #4’s blood glucose was 46 mg/dl or 49 mg/dl as those readings were low, but acknowledged she failed to document if she notified Patient #4’s physician. RN #6 stated she could not recall with certainty if she had notified Patient #4’s physician of Patient #4’s blood glucose below 70 mg/dl. During an interview on 1/4/23 at 12:33 p.m., the DON stated he failed to call Patient #4’s physician on 11/20/23 and 12/13/23 when Patient #4’s blood glucose was 62 mg/dl during the morning visit, which was below 70 mg/dl, the value the SN was ordered to notify Patient #4’s physician on the plan of care. The DON stated during those visits he was focused on ensuring Patient #4’s blood sugar was rising, and not on calling Patient #4’s physician to inform the physician of Patient #4’s low blood glucose. The DON stated he should have notified Patient #4’s physician as ordered on the plan of care.”

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on observation and interview, the agency failed to ensure the director of nursing (DON), who was also the administrator, followed accepted standard infection control practices to prevent the transmission of infections and communicable diseases for 1 of 1 patients observed receiving administration of insulin during a home visit (Patient #4). Findings include: AGENCY POLICY According to an undated agency policy titled, Infection Prevention/Control, (read in pertinent parts): “Agency will observe the recommended precautions for home care as identified by the Centers for Disease and Prevention (CDC). The precautions cover those clients with documented or suspected infection with highly transmissible or epidemiologically important pathogens that require additional precautions to prevent transmission. Standard precautions apply to blood, all body fluids, secretions, excretions, non-intact skin, and mucous membranes. All are to be treated as a potential source of infection regardless of whether the client has a communicable disease. Hands are washed if contaminated with blood or body fluid, immediately after gloves are removed, between client contacts, and when indicated to prevent transfer of microorganisms between other clients or the environment. Gloves are worn when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes, or contaminated items.” 1. The clinical record for Patient #4 was reviewed on 1/2/24. The plan of care for the certification period dated 11/7/23 to 1/5/24 revealed a start of care date of 5/21/21; diagnoses included type two diabetes, heart failure, diverticulosis, stage three chronic kidney disease, acute kidney failure, pulmonary embolism, rheumatoid arthritis, borderline personality disorder, depression, acute respiratory failure with hypoxia, angina, obesity, post-traumatic stress disorder, and pneumonia. Plan of care orders included skilled nurse (SN) visits two times a day for 60 days with three as needed (PRN) visits for assessment including vital signs, monitoring of blood glucose levels, administration of Lantus (a long acting insulin medication) and Humalog (a fast acting insulin medication) administration of Ozempic (a injectable medication used to reduce blood glucose levels in type two diabetics) once a week on Tuesdays, medication set-up, medication compliance, and monitoring of respiratory and cardiac status. a) Observations showed the director of nursing (DON) failed to utilize appropriate infection control procedures during the administration of insulin to Patient #4. A home visit was conducted on 1/3/24 at 7:40 a.m. for Patient #4. The surveyor observed the DON providing care to Patient #4. Upon entering Patient #4’s home, the DON placed a Chux (a disposable pad) on a table and placed his work bag on the Chux. The DON was observed to sanitize his hands. The DON was observed to assess Patient #4’s vital signs and to obtain Patient #4’s blood sugar level from observing the reading on Patient #4’s cell phone as obtained from her continuous monitoring blood glucose device. The DON was observed to document Patient #4’s vital signs and blood glucose level (288 milligrams/deciliter) on the flow sheet which remained in Patient #4’s home along with the notebook the DON used to track this information. The DON then picked up Patient #4’s scale from Patient #4’s living room and moved it into the kitchen to obtain Patient #4’s weight. The DON placed Patient #4’s scale back in her living room and recorded Patient #4’s weight. The DON was observed to then open Patient #4’s refrigerator and remove her Humalog cartridges. Without washing or sanitizing his hands, the DON was observed to open an alcohol swab package and hand the opened package to Patient #4. Patient #4 cleaned her abdomen with the alcohol swab. Without washing/sanitizing his hands or donning gloves, the DON was observed to remove a Humalog cartridge from the plastic bag which contained Patient #4’s Humalog cartridges; set the cartridge to deliver 24 units of Humalog per Patient #4’s blood glucose reading of 288 mg/dl and the sliding scale in Patient #4’s home; apply a needle to the Humalog cartridge; and administer the Humalog into Patient #4’s abdomen. The DON was observed to remove the needle from the Humalog cartridge and dispose of the needle in a plastic bottle. Without washing/sanitizing his hands, the DON placed the Humalog cartridge back in the plastic bag with the rest of Humalog cartridges and placed the cartridges in Patient #4’s refrigerator. During an interview on 1/3/23 at 10:20 a.m., the DON acknowledged the only time he sanitized his hands during the care he provided to Patient #4 at the home visit, on 1/3/24 from approximately 7:40 a.m. until approximately 8:10 a.m., was when he first entered Patient #4’s home. The DON stated he did not feel he needed to wash/sanitize his hands more than upon entering Patient #4’s home, as the equipment he used to obtain Patient #4’s vital signs was clean as he ensured to clean the equipment between patient visits, and thus, the DON did not feel he was at risk to contaminate Patient #4. Additionally, the DON stated he did not see the need to clean his hands or to don gloves when he administered insulin to Patient #4. The DON stated he would start washing/sanitizing his hands and donning gloves prior to administering insulin to a patient and post administration he would wash/sanitize his hands.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on observation, interview and record review, the agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 3 of 6 active patients reviewed (Patients #3, #4 and #7). This deficiency was cited previously during a recertification survey completed on 1/13/21. Although the agency corrected the deficiency, based on the findings below, the agency has not maintained compliance with this regulatory requirement. Findings Include: According to an undated agency policy titled, Physician Orders, (read in pertinent parts): “All medications, treatments and services provided to clients must be ordered by a physician. The agency communicates and integrates orders from all client physicians in the plan of care and assures coordination of all services and interventions provided to the client.” 1. The clinical record for Patient #4 was reviewed on 1/2/24. The plan of care for the certification period dated 11/7/23 to 1/5/24 revealed a start of care date of 5/21/21; diagnoses included type two diabetes, heart failure, diverticulosis, stage three chronic kidney disease, acute kidney failure, pulmonary embolism, rheumatoid arthritis, borderline personality disorder, depression, acute respiratory failure with hypoxia, angina, obesity, post-traumatic stress disorder, and pneumonia. Plan of care orders included skilled nurse (SN) visits two times a day for 60 days with three as needed (PRN) visits for assessment including vital signs, monitoring of blood glucose levels, administration of Lantus (a long acting insulin medication) and Humalog (a fast acting insulin medication) administration of Ozempic (a injectable medication used to reduce blood glucose levels in type two diabetics) once a week on Tuesdays, medication set-up, medication compliance, and monitoring of respiratory and cardiac status. a) The agency failed to ensure Lantus and Humalog were provided as ordered by a physician for Patient #4. Further review of the plan of care showed SN were to administer 33 units of Lantus subcutaneous (injected in fatty tissue under skin) each night and Humalog cartridge 100 units/milliliter (ml) subcutaneous solution sliding scale 20 units for blood glucose (sugar) readings greater than 200 milligrams/deciliter (mg/dl) and 25 units for blood glucose greater than 300 mg/dl administered with meals and hold Humalog if blood glucose less than 200 mg/dl and Ozempic once a week on Tuesdays. Review of a supplemental order written on 11/10/23 by the director of nursing (DON), who was also the administrator, signed by Patient #4’s primary care physician on 12/22/23, showed the following: “Changed medication: 11/10/21- Lantus Solostar Pen 100 units/ml subcutaneous solution 22 units under skin nightly/every evening for diabetes.” Review of a supplemental order written on 11/29/23 by the DON, signed by Patient #4’s primary care physician on 12/22/23, showed the following: “discontinue medication: 11/29/23 Humalog Cartridge 100 units/ml subcutaneous solution sliding scale/BS [blood sugar] 331 30 u subcutaneous (SQ): change medication: [11/29/21] - Humalog Cartridge 100 units/ml subcutaneous solution sliding scale/morning BS 381 28u. Evening BS 381 32 u subcutaneous (SQ)” Review of SN notes from 11/10/23 to 12/22/23 showed Patient #4 did not receive Lantus and/or Humalog as ordered during 76 visits by the following staff: the DON on 34 visits; registered nurse (RN) #2 on 15 visits; RN #6 on 4 visits; and licensed practical nurse (LPN) #3 on 23 visits. During a home visit on 1/3/24 at 7:40 a.m., the surveyor observed after care instructions from Patient #4’s new endocrinologist physician sent home with Patient #4 on 11/10/23 and 11/29/23 instructing Patient #4 how much Lantus to take each night and how much Humalog to take at breakfast, lunch and dinner based on her blood glucose levels. During a home visit on 1/3/24 at 7:40 a.m., Patient #4 stated she first saw her new endocrinologist on 11/10/23 and he started her on a new sliding scale for her Humalog and changed her Lantus dosage. Patient #4 stated this same physician gave her an updated Humalog sliding scale and new dosage of Lantus on 11/29/23. Patient #4 stated SNs came from the agency two times a day to assist her with monitoring her blood glucose, medication set-up and administering her Lantus, Humalog and Ozempic. Patient #4 stated although her endocrinologist recommended three times daily Humalog injections depending on her blood glucose levels, she only wanted a SN to come assist her with injecting her Humalog two times a day. Cross Reference G718 During an interview on 1/3/24 at 2:10 p.m., LPN #3 stated she observed the after care instructions provided to Patient #4 by her endocrinologist on 11/10/23 and 11/29/23 and assumed these after care instructions were orders to the agency for how much Humalog and Lantus to administer Patient #4, and thus, she used these after care instructions to guide how much Humalog and Lantus she administered Patient #4. During an interview on 1/4/24 at 10:32 a.m., RN #6 stated Scheduler #7 informed her when Patient #4’s Humalog and Lantus changed. RN #6 stated she observed the after care instructions provided to Patient #4 on 11/10/23 and 11/29/23 and followed those instructions along with corresponding instructions on Patient #4’s medication profile in the agency’s electronic medical record (EMR) to know how much Lantus and Humalog to administer. RN #6 stated she did not contact Patient #4’s primary care physician or endocrinologist to verify the after care instructions as the DON was Patient #4’s RN case manager and it it was his responsibility to obtain orders for Patient #4. During an interview on 1/4/24 at 10:55 a.m., RN #2 stated the DON informed her of the new Lantus and Humalog instructions provided to Patient #4 on 11/10/23 and 11/29/23 and RN #2 observed these after care instructions in Patient #4’s home. RN #2 assumed the after care instructions provided to Patient #4 on 11/10/23 and 11/29/23 were also orders for Patient #4, and thus, she followed these instructions without verifying them with Patient #4’s primary care or endocrinology physicians. During an interview on 1/4/24 at 12:00 p.m., the DON confirmed he was Patient #4’s RN case manager. The DON stated on 11/10/23 and 11/29/23 he observed the after care instructions provided to Patient #4 by her endocrinologist and mistakenly assumed these after care instructions were also orders for the agency on how much Humalog and Lantus to administer. The DON stated he did write clarification orders regarding these instructions on 11/10/23 and 11/29/23 and sent these instructions to Patient #4’s primary care physician for approval. The DON stated he did not seek a verbal order from either Patient #4’s primary care physician or her endocrinologist due to his incorrect assumption of the Patient #4’s after care instructions being orders for the agency. The DON reviewed the order he wrote on 11/10/23 to clarify how much Lantus Patient #4 was to take. The DON stated the date of 11/10/21 on the 11/10/23 order was a typo and he could not state why the Lantus dose of 22 units at night was the dose listed on the 11/10/23 clarification order as on the 11/10/23 after care instruction provided to Patient #4, the Lantus dose was listed as 28 units. The DON could not explain why the 11/10/23 clarification order failed to have the new Humalog scale documented and could not explain why the 11/29/23 order did not have the new Lantus dose of 22 units listed. The DON stated in the future he would ensure the first SN to observe after care instructions to a patient called physicians to verify the after care instructions to obtain a verbal order and he would ensure clarification/verbal orders were written correctly. b) The agency failed to ensure a physician order was obtained for RN #6 to install a Dexcom continuous glucose monitor and to replace the sensor in this monitor for Patient #4. Further review of Patient #4’s plan of care for the certification period dated 11/7/23 to 1/5/24 revealed Patient #4’s durable medical equipment included a walker and oxygen. Review of supplemental orders failed to show an order for the agency’s SN to assist Patient #4 with installing a continuous glucose monitor or replacing the sensor in the continuous glucose monitor. Review of a SN note on 12/3/23 for the morning visit, showed RN #6 documented she assisted Patient #4 to install her new G7 Dexcom continuous glucose monitor and to set up the receiver. RN #6 documented she educated Patient #4 how to use and navigate the receiver to look at reports and to see her glucose levels in real time. RN #6 failed to obtain an order to assist Patient #6 with installing her G7 Dexcom continuous glucose monitor and setting up the receiver. Review of a SN note on 12/16/23 for the morning visit., showed RN #6 installed a new G7 Dexcom continuous glucose sensor. RN #6 failed to have a physician order to assist Patient #4 with installing a new sensor in Patient #4’s G7 Dexcom continuous glucose monitor. During a home visit on 1/3/24 at 7:40 a.m., Patient #4 stated in the past two to three months she started to use a continuous glucose monitor and the agency SNs used the values from her continuous glucose monitor to know how much Humalog to administer to her. Patient #4 stated prior to her using a continuous glucose monitor, the SNs at the agency used a standard glucometer to monitor her blood glucose. Patient #4 stated the SNs at the agency continued to use the glucometer if her continuous glucose monitor was not functioning correctly. During an interview on 1/4/24 at 10:23 a.m., RN #6 confirmed she had installed Patient #4’s new G7 Dexcom continuous glucose monitor on 12/3/23 during the morning visit. RN #6 stated she assisted Patient #4 to install the G7 Dexcom continuous glucose monitor and set up the receiver at Patient #4’s request. RN #6 stated Patient #4 informed her the other SNs at the agency had informed Patient #4 they did not know how to install her new G7 Dexcom continuous glucose monitor. RN #6 stated she was familiar with how to install a G7 Dexcom continuous glucose monitor and its receiver, thus she assist Patient #4. Additionally, RN #6 confirmed on 12/16/23 during the morning visit,. she assisted Patient #4 to change the sensor in her G7 Dexcom continuous glucose monitor. RN #6 acknowledged she did not have a physician order to install the G7 Dexcom continuous glucose monitor, to set up the receiver or to change the sensor. RN #6 stated she did not think to obtain an order for any of these treatments as Patient #4 had used a different brand of continuous glucose monitoring, a Freestyle, for a month or two prior. RN #6 stated since Patient #4 was changing the brand of continuous glucose monitoring, she did not think an order was necessary. RN #6 acknowledged she did not know who installed Patient #4’s previous continuous glucose monitor. During an interview on 1/4/24 at 12:24 p.m., the DON stated Patient #4 started to use a Freestyle continuous glucose monitor approximately two months ago. The DON stated he did not know who installed the Freestyle continuous glucose monitor. The DON acknowledged Patient #4’s plan of care failed to list she had a continuous glucose monitor or how to care for it as he did not think he needed to include this information on Patient #4’s plan of care. The DON also acknowledged RN #6 failed to have an order to install the G7 Dexcom continuous glucose monitor, set up its receiver and to change it’s sensor two weeks later. The DON stated he was not aware who was responsible for managing Patient #4’s continuous glucose monitor, but acknowledged agency SNs used this monitor to obtain blood glucose levels to determine how much Humalog to administer Patient #4. The DON stated he would investigate with Patient #4’s physician to determine what the agency was responsible for and allowed to do in regards to Patient #4’s continuous glucose monitor and update Patient #4’s plan of care. 2. The clinical record for Patient #3 was reviewed on 1/2/24. The plan of care for the certification period dated 11/29/23 to 1/27/24, signed by Patient #3’s physician on 1/4/24, revealed a start of care date of 6/2/23; diagnoses included cerebral infarction, pressure ulcers of the left ankle, right heel and unspecified site, weakness, peripheral vascular disease, constipation and other specified intestinal infections. Plan of care orders included SN three times a week for nine weeks with three PRN visits for assessment, education and wound care to right heel, left ankle, and left calf as follows: remove old dressing and cleanse the wound with saline or wound cleanser, removing any old iodosorb (a gel applied to wet wounds used to kill bacteria, absorb exudate (pus) and clean wounds to assist with healing; apply skin prep to periskin; apply iodosorb to wound bed; cover the wound with ABD pad (wound dressing used to absorb drainage) and secure with Kerlix (rolled gauze) and tape. SN orders also included applying Clear Aid (a medication used to treat minor skin irritations) to buttocks. Home Health Aide (HHA) orders included visits three times a day for 60 days for assistance with bathing, dressing oral care, skin care including applying Clear Aid up to three times a day to Patient #3’s buttocks, medication reminding, transfers, incontinence care, equipment cleaning, and informing SN of any break down in skin integrity. a) The agency failed to ensure wound care was provided only as ordered by the physician. Review of a supplemental order written 11/27/23 by RN #2, who was also the alternate administrator, effective 11/25/23 and signed by Patient #3’s physician on 1/4/24 showed wound care was discontinued for the following wounds, as they had closed/healed: coccyx, left knee, left foot and left toe callus. Patient #3 had a new wound on her right heel and left ankle. Wound care to left calf, left ankle and right heel was to be completed as follows three times a week: remove old dressing and cleanse with saline or wound cleanser ensuring to remove any old iodosorb; apply skin prep to periskin; apply iodosorb to the wound bed; and cover each wound with an ABD pad and secure with Kerlix and tape. The order stated Patient #3’s physician office did not provide verbal orders. Review of agency fax records showed the agency sent this order to be signed by Patient #3’s physician on 12/7/23 (10 days after the order was written by RN #2) and again on 12/21/23 (14 days after the order was initially sent out for signature). Review of a wound care clinic order dated 12/14/23 and received by the agency via fax machine on 12/14/23 at 1:08 p.m. stated Patient #3 was to receive the following wound care to her left lower extremity: cleanse with normal saline and pat dry; paint wound beds with iodine, wrap lower extremity with Kerlix for protection and secondary bandages could be utilized as needed. Review of SN notes from 12/6/23 to 12/29/23 showed LPN #3 documented she provided wound care to Patient #3’s left calf, left ankle and right heel as follows: remove old dressing, cleanse each wound with saline removing old iodosorb, apply skin prep to periskin, apply iodosorb to wound bed, cover right heel with a foam border dressing and left calf and ankle covered with ABD pad, secured with Kerlix and tape. LPN #3 failed to have orders for all wound care to Patient #3’s left calf and left ankle for wound care provided 12/6/23, 12/8/23, 12/11/23 and 12/13/23 as the agency did not receive the wound care clinic order until 12/14/23 and the order written by RN #2 was not signed by Patient #3’s physician until 1/4/23. LPN #3 failed to have orders for the wound care provided to Patient #3’s right heel on the 11 times between 12/6/23 -12/29/23 (12/6/23, 12/8/23, 12/11/23, 12/13/23, 12/15/23, 12/18/23, 12/20/23, 12/22/23, 12/25/23, 12/27/23, 12/29/23) as the 11/25/23 order written by RN #2, which was not a verbal order, was not signed until 1/4/24. During a home visit on 1/5/24 at 1:59 p.m., LPN #3 stated RN #2 communicated to her via a telephone call, sometime during the week of 11/26/23- 12/2/23, during RN #2’s recertification visit on 11/25/23, RN #2 determined Patient #3’s coccyx, left knee, left foot and left toe callus wounds were closed. RN #2 also determined Patient #3’s left calf wound was significantly larger and Patient #3 had developed new wounds on her left ankle and right heel. LPN #3 stated RN #2 informed her of the treatment she recommended LPN #3 complete for the three wounds and LPN #3 observed the order written on 11/27/23 effective 11/25/23 by RN #2 in the agency’s electronic medical record (EMR). LPN #3 stated she also was aware the wound care clinic came to see Patient #3 on 12/14/23 and she observed the orders in EMR provided by the wound care clinic on 12/14/23 and LPN #3 followed those orders for wound care provided to Patient #3. During an interview on 1/4/24 at 9:59 a.m., RN #2 stated Patient #3’s physician would not provide verbal orders. RN #2 stated after she reassessed Patient #3 on 11/25/23, she placed a phone call to Patient #3’s physician office on approximately 11/27/23 asking for a call back to discuss Patient #3’s wounds. RN #3 spoke with an RN at Patient #3’s physician office and informed the physician office RN Patient #3’s wounds on her coccyx, left knee, left foot and left toe callus were closed, Patient #3’s left calf wound had enlarged and Patient #3 had developed new wounds on her left ankle and right heel. RN #2 stated the physician office RN and RN #2 discussed treatment for Patient #3’s remaining three wounds including having a wound care clinic come out to Patient #3’s home to complete an assessment and advise the agency on further wound care treatments. RN #2 stated once she wrote an order, office personnel in the agency office were responsible for faxing the order to the physician for signature. During an interview on 1/4/24 at 1:06 p.m., the DON stated RN #2 informed him of Patient #3’s enlarged left calf wound and the discussion with Patient #3’s physician office to have a wound care clinic come out to assess Patient #3 to advise the agency on wound care treatments for her wounds. The DON acknowledged Patient #3’s order written on 11/27/23 by RN #2 effective 11/25/23 for wound care for Patient #3’s left calf, left ankle and right heel wound was not signed by Patient #3’s physician office until 1/4/24. The DON stated the agency struggled with getting orders signed in a timely manner with some physician offices and agreed this was especially an issue with physician offices who did not provide verbal orders. The administrator stated he was in the process of creating a wound care book to track all patients with wounds, what treatment each wound was to receive and what date the agency received the order. The DON hoped this book would help reduce this deficient practice. 3. The clinical record for Patient #7 was reviewed on 1/4/24. The plan of care for the certification period dated 12/26/23 to 2/23/24, revealed a start of care date of 12/26/23; diagnoses included type two diabetes, pain in right and left shoulder, acute posthemorrhagic anemia, depression, bilateral astigmatism, dizziness, tinnitus, and Vitamin D deficiency. Plan of care orders include SN visits two times a day for 60 days with three PRN visits for assessment, blood sugar monitoring, administration of subcutaneous insulin, administration of subcutaneous Trulicity (a once weekly injectable medication used to help type two diabetics release its own insulin), medication set-up and medication compliance. The plan of care for the certification period dated 10/7/23 to 12/5/23, revealed a start of care date of 12/21/20; diagnoses included type two diabetes, pain in right and left shoulder, acute posthemorrhagic anemia, depression, bilateral astigmatism, dizziness, tinnitus, and Vitamin D deficiency. Plan of care orders include SN visits two times a day for 60 days with three PRN visits for assessment, blood sugar monitoring, administration of subcutaneous insulin, administration of subcutaneous Trulicity, medication set-up and medication compliance. a) The agency failed to ensure orders were obtained to start care with the patient. Review of Patient #7’s clinical record revealed RN #2 completed a comprehensive assessment for Patient #7 on 12/26/23. Additionally, record review revealed on 12/26/23, RN #2 assessed Patient #7 including taking her vital signs and monitoring Patient #7’s blood glucose level. RN #2 found Patient #7’s blood glucose level to be 392 mg/dl, thus, RN #2 administered 21 units of NPH 70/30 (type of insulin) subcutaneously to Patient #7’s lower abdominal region. RN #2 also completed a diabetic foot check, assessed Patient #7’s medication compliance, completed medication set-up, and educated Patient #7 and her family on diabetic diet, diabetic foot care, number rating scale for pain, infection control, safety in the home/fall prevention, and flu/Covid/RSV prevention. Review of SN note on 12/27/23 during the morning visit, showed the DON assessed Patient #7, including taking her vital signs, assessing her dietary and hydration status, completed a diabetic foot check, educated Patient #7 on infection control measures, monitored Patient #7’s blood glucose level. The DON found Patient #7’s blood glucose level to be 231 mg/dl, thus, administered 28 units of NPH 70/30 subcutaneously. Review of a SN note on 12/27/23 during the afternoon visit, showed LPN #3 obtained Patient #7’s vital signs, assessed Patient #7’s dietary and hydration status, completed a diabetic foot check, ensured Patient was compliant with taking her medication, educated patient #7 on the American Diabetic Association diet recommendations, and monitored Patient #7’s blood glucose level. LPN #3 found Patient #7’s blood glucose level to be 344 mg/dl, thus, administered 21 units of NPH 70/30 in Patient #7’s left upper abdomen. Further review of Patient #7’s clinical record on 1/5/24 showed Patient #7 was put on hold for care on 10/22/23 as she went out of the country and she was discharged from the agency on 12/5/23 when her certification expired as she still had not returned to her home. On 12/26/23 the DON wrote a start of care order to resume SN visits two times a day for 60 days with three PRN visits for preparing and administering insulin two times a day and weekly medication set-up. This order was faxed to Patient #7’s physician on 12/26/23. On 12/27/23, Patient #7’s physician documented on this start of care order a verbal order received and read back on 12/27/23 by Patient #7’s physician assistant (PA) and Patient #7’s PA signed the order on 12/28/23. During an interview on 1/4/24 at 11:07 a.m., RN #2 stated someone at the agency, she could not recall specifically who contacted her, contacted her to inform her Patient #7 had returned from her vacation out of the country and was ready to resume care on 12/26/23. RN #2 stated she was not responsible for obtaining start of care orders. RN #2 stated the DON was responsible for ensuring all patients had start of care orders. RN #2 stated she did not call Patient #7’s physician after she completed her assessment on 12/26/23 as Patient #7’s care had not changed from her previous admission and RN #2 assumed the DON had obtained start of care orders for Patient #7 prior to her 12/26/23 assessment and visit. During an interview on 1/4/24 at 12:59 p.m., the DON acknowledged he did not call Patient #7’s physician to obtain a new start of care order for 12/26/23. The DON stated when Patient #7’s family contacted the agency to inform them Patient #7 had returned from her vacation and required services to begin again, RN #2 was scheduled to go out and assess Patient #7 on 12/26/23. The DON stated on 12/26/23 he wrote the start of care orders, but failed to obtain a verbal order for this resumption of care and the agency did not receive the signed order to resume care for Patient #7 until 12/28/23, two days after the agency had provided Patient #7 with care. The DON stated the agency did not expect RN’s to obtain verbal orders at the start of care as the agency assumed their referral order was the agency’s orders. The DON acknowledged some referral orders were not detailed with all orders for the agency staff and/or the referral order, as in the case for Patient #7, was not signed timely, thus the agency was providing care without orders. The administrator stated he would instruct his staff to obtain verbal orders in the future to bridge the gap until the agency received signed orders.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled professionals assumed responsibility for preparing and maintaining accurate and complete clinical notes for 3 of 7 patients who received skilled nursing (SN) services (Patients #3, #4 and #7). Findings include: AGENCY POLICY According to an undated agency policy titled, Clinical Documentation, (read in pertinent parts): “Agency will document each direct contact with the client. To ensure that there is an accurate record of the services provided, client response and ongoing need for care.” 1. The clinical record for Patient #3 was reviewed on 1/2/24. The plan of care for the certification period dated 11/29/23 to 1/27/24, signed by Patient #3’s physician on 1/4/24, revealed a start of care date of 6/2/23; diagnoses included cerebral infarction, pressure ulcers of the left ankle, right heel and unspecified site, weakness, peripheral vascular disease, constipation and other specified intestinal infections. Plan of care orders included SN three times a week for nine weeks with three PRN visits for assessment, education and wound care to right heel, left ankle, and left calf as follows: remove old dressing and cleanse the wound with saline or wound cleanser, removing any old iodosorb (a gel applied to wet wounds used to kill bacteria, absorb exudate (pus) and clean wounds to assist with healing; apply skin prep to periskin; apply iodosorb to wound bed; cover the wound with ABD pad (wound dressing used to absorb drainage) and secure with Kerlix (rolled gauze) and tape. SN orders also included applying Clear Aid (a medication used to treat minor skin irritations) to buttocks. Home Health Aide (HHA) orders included visits three times a day for 60 days for assistance with bathing, dressing oral care, skin care including applying Clear Aid up to three times a day to Patient #3’s buttocks, medication reminding, transfers, incontinence care, equipment cleaning, and informing SN of any break down in skin integrity. a) The agency failed to ensure licensed practical nurse (LPN) #3 documented accurately which wounds she provided wound care at each visit. Review of a supplemental order written 11/27/23 by registered nurse (RN) #2, who was also the alternate administrator, effective 11/25/23 and signed by Patient #3’s physician on 1/4/24, showed wound care was discontinued for the following wounds, as they had closed/healed: coccyx, left knee, left foot and left toe callus. Patient #3 had a new wound on her right heel and left ankle. Wound care to left calf, left ankle and right heel as follows three times a week: remove old dressing and cleanse with saline or wound cleanser ensuring to remove any old iodosorb; apply skin prep to periskin; apply iodosorb to the wound bed; and cover each wound with an ABD pad and secure with Kerlix and tape. The order stated Patient #4’s physician office did not provide verbal orders. Review of agency fax records showed the agency sent this order to be signed by Patient #3’s physician on 12/7/23 (10 days after the order was written by RN #2) and again on 12/21/23 (14 days after the order was initially sent out for signature). Cross Reference G580 Review of a wound care clinic order dated 12/14/23, received by the agency via fax machine on 12/14/23 at 1:08 p.m., stated Patient #3 was to receive the following wound care to her left lower extremity: cleanse with normal saline and pat dry; paint wound beds with iodine, wrap lower extremity with Kerlix for protection and secondary bandages could be utilized as needed. Review of a SN note for Patient #3 written on 11/25/23 showed RN #2 documented wound care had been discontinued for the following wounds as the wounds were closed and had healed: coccyx, left knee, left foot, right ankle, and left toe callus. RN #2 documented Patient #3 had a new right heel (stage 3) and left ankle (stage 3) wound . RN #2 documented Patient #3’s left calf wound had increased in size from 4.3 centimeters (cm) x 2.0 cm x 0.3 cm to 18.1 cm x 2.9 cm x 0.4 cm. RN #2 documented she provided wound care to Patient #2’s left calf, left ankle and right heal as follows: remove old dressing and cleanse with saline or wound cleanser, removing any old iodosob, apply skin prep to periskin, apply iodosob to wound bed, cover wounds with ABD pad and secure with Kerlix and tape. Apply Clear Aid to buttocks and HHA may apply up Clear Aid up to three times a day. Review of SN notes for Patient #3 written on 11/27/23- 12/4/23 showed LPN #3 documented the following: wound care to right ankle (stage 2) measurements 0.8 x 0.8 x 0 cm, left foot (stage 2) measurements 1.5 x 1.0 x 0.1 cm, left calf (unstageable) measurements 4.3 x 2.0 x 0.3 cm, left knee (unstageable) as follows: removed old dressing, cleansed with saline removing old iodosorb, skin prep applied to periskin, and iodosorb applied to wound bed. Right ankle and left knee covered with a foam border dressing and left foot and left calf covered with an ABD pad and secured with Kerlix and tape. Coccyx wound measured 0.4 x 0.4 x 0.1 cm. Coccyx wound cleansed with incontinence wipes and hydrophilic wound dressing (a type of wound dressing which reduces the possibility of antimicrobial resistance) applied to open areas, along with Clear Aid ointment applied around the wound and buttocks left open to air. Left toe callus cleansed with no rinse foam cleanser, nutrashield applied (a wound ointment which provides moisture barrier while relieving dryness) and left open to air. Review of SN notes for Patient #3 from 12/6/23 to 12/29/23 showed LPN #3 documented she provided wound care to Patient #3’s left calf, left ankle and right heel wound. During a home visit on 1/3/24 at 1:26 p.m., Patient #3’s husband confirmed LPN #3 and RN #2 were the primary SNs who provided Patient #3 with SN care. Patient #3’s husband stated LPN #3 and RN #2 took good care of Patient #3 and her wounds were healing as a result of their care. During a home visit on 1/3/24 at 1:26 p.m., the surveyor observed LPN #2 provide care to Patient #3’s left calf, left ankle and right heel wounds. During a home visit on 1/3/24 at 1:59 p.m., LPN #3 confirmed she provided Patient #3 with SN visits three times a week for vital sign monitoring, medication compliance and wound care. LPN #3 stated RN #2 was Patient #3’s RN case manager and LPN #3 and RN #2 communicated frequently about Patient #3’s needs. LPN #3 stated she had discussed with RN #2 that Patient #3’s coccyx, left knee, left foot and left toe wounds were healed and closed prior to RN #2’s reassessment of Patient #3 on 11/25/23. LPN #3 asked RN #2 to assess these wounds and the new wounds on Patient #2’s left ankle and right heel along with the worsening of Patient #3’s left calf wound. LPN #3 stated she recalled receiving a phone call from RN #2 during the week of 11/27/23 to 12/3/23, and she thought she spoke with RN #2 on Monday 11/27/23, about RN #2 agreeing Patient #3’s coccyx, left knee, left foot, and left toe wounds being closed and the treatment recommendations for Patient #3’s worsening left calf wound and her new left ankle and right heel wounds. LPN #3 stated on 11/27/23, 11/29/23, 12/12/23 and 12/4/23 she would have provided care to Patient #3’s left calf, left ankle and right heel wounds as she treated the wounds Patient #3 had present and she could not explain why her notes indicated she instead provided care to Patient #3’s coccyx, left knee, left foot, left calf and left toe wound and did not provide care to Patient #3’s left ankle and right heel wound. During an interview on 1/4/24 at 10:44 a.m., RN #2 confirmed she was Patient #3’s RN case manager and she supervised LPN #3’s care of Patient #3. RN #2 stated she had communicated with LPN #3 before and after the reassessment RN #2 completed on 11/25/23 and LPN #2 was aware Patient #3’s coccyx, left knee, left foot and left toe wounds were closed and healed. RN #2 also stated LPN #3 was aware Patient #3 had developed a worsening left calf wound along with new wounds on her left ankle and right heel with the treatment recommendations for these three wounds. RN #2 reviewed LPN #3’s notes for Patient #3 from 11/27/23 to 12/4/23 and stated she thought LPN #3 had a documentation error for those four visits. RN #2 stated Patient #3 had many wounds throughout her course of care, and sometimes it was confusing what wounds were being treated. RN #2 stated the agency’s electronic medical record (EMR) system would pull the previous note over each visit. RN #2 stated LPN #3 might have accidentally used an old note to document the wounds LPN #3 provided Patient #3 with care on 11/27/23 to 12/4/23. During an interview on 1/4/23 at 1:06 p.m., the director of nursing (DON), who was also the administrator, stated he was responsible for reviewing SN notes for patients. The DON reviewed Patient #3’s 11/25/23 SN note completed by RN #2 and the 11/27/23 to 12/6/23 SN notes completed by LPN #3 and acknowledged the wound measurements and wounds treated by RN #2 on 11/25/23 did not match with the wound measurements and wounds treated by LPN #3 on 11/27/23 through 12/4/23. The DON stated LPN #3 and RN #2 had discussed this finding with him after the surveyor had interviewed them, and he felt LPN #3 had accidentally misdocumented which wounds she measured and treated 11/27/23 to 12/4/23. The administrator stated he had recently begun a project to develop a wound care binder where he would be tracking all patient’s wound, along with the ordered treatments for each wound and care provided at each visit. The administrator stated he felt this new wound care binder would help the agency catch documentation errors such as occurred by LPN #3. 2. The clinical record for Patient #7 was reviewed on 1/4/24. The plan of care for the certification period dated 12/26/23 to 2/23/24, revealed a start of care date of 12/26/23; diagnoses included type two diabetes, pain in right and left shoulder, acute posthemorrhagic anemia, depression, bilateral astigmatism, dizziness, tinnitus, and Vitamin D deficiency. Plan of care orders include SN visits two times a day for 60 days with three PRN visits for assessment, blood sugar monitoring, administration of subcutaneous insulin, administration of subcutaneous Trulicity (a once weekly injectable medication used to help type two diabetics release its own insulin) 1.5 milligrams (mg) once a week, medication set-up and medication compliance. The plan of care for the certification period dated 10/7/23 to 12/5/23, revealed a start of care date of 12/21/20; diagnoses included type two diabetes, pain in right and left shoulder, acute posthemorrhagic anemia, depression, bilateral astigmatism, dizziness, tinnitus, and Vitamin D deficiency. Plan of care orders include SN visits two times a day for 60 days with three PRN visits for assessment, blood sugar monitoring, administration of subcutaneous insulin, administration of subcutaneous Trulicity 1.5 milligrams (mg) once a week, medication set-up and medication compliance. a) The DON failed to document when he administered Trulicity to Patient #7. Review of Patient #7’s SN notes from 10/8/23 to 10/14/23 failed to show the DON administered 1.5 mg Trulicity to Patient #7. Review of SN notes from 10/15/23 to 10/21/23 and 12/26/23 to 12/30/23 showed the DON documented on the 10/20/23 a.m. visit note and the 12/29/23 a.m. visit note he administered 1.5 mg of Ozemipc (a injectable medication used to reduce blood glucose levels in type two diabetics) subcutaneously into Patient #7. During an interview on 1/4/24 at 12:43 p.m., the DON stated he was Patient #7’s RN case manager and the only SN who administered Trulicity for Patient #7. The DON stated he administered Trulicity to Patient #7 on Fridays. The DON stated due to Patient #7’s missed visit due to a doctors appointment on Friday 10/13/23, he gave Patient #7 her Trulicity injection at the next visit he provided to her, which was on 10/14/23 in the late afternoon. The DON acknowledged he failed to document he had provided Patient #7 with her Trulicity. The DON stated Patient #7 did not have Ozempic ordered nor did he ever administer Ozempic to Patient #7. The DON stated he mistakenly documented he administered 1.5 mg of Ozempic on 10/20/23 and 12/29/23 and should have documented he administered 1.5 mg of Trulicity. 3. The clinical record for Patient #4 was reviewed on 1/2/24. The plan of care for the certification period dated 11/7/23 to 1/5/24 revealed a start of care date of 5/21/21; diagnoses included type two diabetes, heart failure, diverticulosis, stage three chronic kidney disease, acute kidney failure, pulmonary embolism, rheumatoid arthritis, borderline personality disorder, depression, acute respiratory failure with hypoxia, angina, obesity, post-traumatic stress disorder, and pneumonia. Plan of care orders included skilled nurse (SN) visits two times a day for 60 days with three as needed (PRN) visits for assessment including vital signs, monitoring of blood glucose levels, administration of Lantus a long acting insulin medication) and Humalog (a fast acting insulin medication) administration of Ozempic (a injectable medication used to reduce blood glucose levels in type two diabetics) once a week on Tuesdays, medication set-up, medication compliance, and monitoring of respiratory and cardiac status. a) The DON failed to document when he administered Ozempic to Patient #4. Review of SN notes for Patient #4 from 10/1/23 to 1/2/24 showed Patient #4 was not administered Ozempic the week of 11/19/23 to 11/25/23 or on 1/2/24. During a home visit on 1/3/24 at 7:40 a.m., Patient #4 confirmed the DON provided her with her once weekly Ozempic shots on Tuesdays and stated he never missed a visit with Patient #4. During an interview on 1/4/24 at 12:22 p.m., the DON stated he administered Patient #4 1.5 mg of Ozempic subcutaneously each Tuesday as ordered on the plan of care. The DON stated he administered Ozempic on Tuesday 11/21/23 and 1/2/24 during Patient #4’s morning visits and he must have forgotten to document this in his notes. 4. During an interview on 1/4/24 at 1:06 p.m., the DON stated agency staff, including himself, needed to improve on their documentation.”

“Communication with physicians CFR(s): 484.75(b)(7) Communication with all physicians involved in the plan of care and other health care practitioners (as appropriate) related to the current plan of care; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure skilled professional services communicated with the physician involved in the plan of care and other health care practitioners related to the current plan of care for 2 of 6 active patients reviewed (Patients #2 and #4). Findings include: AGENCY POLICY According to an undated agency policy titled, Coordination of Client Services, (read in pertinent parts): “All personnel furnishing services shall maintain a liaison to assure that their efforts are coordinated effectively and support the objectives outlined in the Plan of Care. This may be done through formal care conferences; maintaining complete, current Care Plans; and written and verbal interaction.” 1. The clinical record for Patient #4 was reviewed on 1/2/24. The plan of care for the certification period dated 11/7/23 to 1/5/24 revealed a start of care date of 5/21/21; diagnoses included type two diabetes, heart failure, diverticulosis, stage three chronic kidney disease, acute kidney failure, pulmonary embolism, rheumatoid arthritis, borderline personality disorder, depression, acute respiratory failure with hypoxia, angina, obesity, post-traumatic stress disorder, and pneumonia. Plan of care orders included skilled nurse (SN) visits two times a day for 60 days with three as needed (PRN) visits for assessment including vital signs, monitoring of blood glucose levels, administration of Lantus (a long acting insulin medication) and Humalog (a fast acting insulin medication) administration of Ozempic (a injectable medication used to reduce blood glucose levels in type two diabetics) once a week on Tuesdays, medication set-up, medication compliance, and monitoring of respiratory and cardiac status. a) The director of nursing (DON) failed to communicate with Patient #4’s endocrinologist to inform him/her Patient #4 declined to have SN visits three times a day to assist her with administration of Humalog. Further review of the plan of care showed SNs were to administer 33 units of Lantus subcutaneous (injected in fatty tissue under skin) each night and Humalog cartridge 100 units/milliliter (ml) subcutaneous solution sliding scale 20 units for blood glucose readings greater than 200 milligrams/deciliter (mg/dl) and 25 units for blood glucose greater than 300 mg/dl administered with meals and hold Humalog if blood glucose less than 200 mg/dl. Review of a supplemental order written on 11/10/23 by the DON, who was also the administrator, signed by Patient #4’s primary care physician on 12/22/23, showed the following: “Changed medication: 11/10/21- Lantus Solostar Pen 100 units/ml subcutaneous solution 22 units under skin nightly/every evening for diabetes.” Review of a supplemental order written on 11/29/23 by the DON, signed by Patient #4’s primary care physician on 12/22/23 showed the following: “discontinue medication: 11/29/23 Humalog Cartridge 100 units/ml subcutaneous solution sliding scale/BS [blood sugar] 331 30 u subcutaneous (SQ): change medication: [11/29/21] - Humalog Cartridge 100 units/ml subcutaneous solution sliding scale/morning BS 381 28u. Evening BS 381 32 u subcutaneous (SQ)” During a home visit on 1/3/24 at 7:40 a.m., the surveyor observed after care instructions from Patient #4’s new endocrinologist physician sent home with Patient #4 on 11/10/23 and 11/29/23 instructing Patient #4 how much Lantus to take each night and how much Humalog to take at breakfast, lunch and dinner based on her blood glucose levels. Review of SN notes from 11/10/23 to 1/1/24 showed Patient #4 received SN visits two times a day. During a home visit on 1/3/24 at 7:40 a.m., Patient #4 stated she first saw her new endocrinologist on 11/10/23 and he started her on a new sliding scale for her Humalog and changed her Lantus dosage. Patient #4 stated this same physician gave her an updated Humalog sliding scale and new dosage of Lantus on 11/29/23. Patient #4 stated agency SNs came two times a day to assist her with monitoring her blood glucose, medication set-up and administering her Lantus, Humalog and Ozempic. Patient #4 stated although her endocrinologist recommended three times daily Humalog injections depending on her blood glucose levels, she only wanted SNs to come assist her with injecting her Humalog two times a day. During an interview on 1/3/24 at 2:10 p.m., licensed practical nurse (LPN) #3 stated she observed Patient #4’s after care instructions, provided to Patient #4 on 11/10/23 and 11/29/23 by her endocrinologist, advising Patient #4 to have Humalog administered three times a day at breakfast, lunch, and dinner. LPN #3 stated she was not sure how Patient #4 complied with these instructions as agency SNs provided Patient #4 with visits in the morning and late afternoon/early evening and did not provide her with a lunch time visit. LPN #3 stated Patient #4 was offered a lunch time visit by the agency, but Patient #4 refused to have a SN come more than twice a day. During an interview on 1/4/24 at 10:35 a.m., registered nurse (RN) #6 stated she was not sure how Patient #4 received her lunch time dose of Humalog. RN #6 stated she was a PRN nurse for the agency and she provided Patient #4 with visits as instructed by the agency and it was not her responsibility to ensure Patient #4 received all care as instructed by her physicians, this was the RN case manager’s responsibility. RN #6 stated the DON was Patient #4’s RN case manager. During an interview on 1/4/24 at 11:02 a.m., RN #2 stated Patient #4 refused to have agency SN provide more than two times a day SN visits. RN #2 stated she did not know how Patient #4 received the lunch time Humalog as instructed by Patient #4’s endocrinologist on 11/10/23 and 11/29/23. RN #2 stated Patient #4’s primary care physician was aware Patient #4 would only allow the SNs to provide two times a day visits, but she was not sure if Patient #4’s endocrinologist, who recommended to Patient #4 administer Humalog three times a day, depending on Patient #4’s blood glucose level, was aware Patient #4 received SN visits two times and not three times a day. During an interview on 1/4/24 at 12:11 p.m., the DON confirmed he was Patient #4’s RN case manager. The DON stated he had never communicated with Patient #4’s endocrinologist. The DON stated when Patient #4 returned from her visit visit with her new endocrinologist on 11/10/23 and 11/29/23 the endocrinologist sent Patient #4 home with after care instructions. The DON stated these after care instructions included a dosage for Patient #4’s evening Lantus and a sliding scale for her Humalog for breakfast, lunch and dinner that was different from Patient #4’s plan of care orders. The DON assumed these after care instructions were also orders for the agency so the DON did not contact either Patient #4’s primary care physician or the endocrinologist to verify these instructions and obtain orders for the agency. The DON did attempt to write clarification orders for both of these after care instructions, but acknowledge he wrote these clarification orders incorrectly. Cross Reference G580. Further, the DON stated he observed the after care instructions provided to Patient #4 on 11/10/23 and 11/29/23 by her endocrinologist recommended Patient #4 receive Humalog three times a day at breakfast, lunch and dinner. The DON stated he discussed this with Patient #4 and offered to send SNs out three times a day, but Patient #4 adamantly refused to have the SN come more than two times a day. The DON stated he did not inform either the primary care physician or the endocrinologist of Patient #4 refusing three times a day SN visits. The DON stated he assumed when he sent the primary care doctor the clarification order which stated the agency was providing SN two times a day on the 11/29/23 clarification order, Patient #4’s primary care doctor would be aware Patient #4 was not receiving SN three times a day, and thus, not receiving Humalog three times a day as recommended by the endocrinologist. The DON stated he did not think to communicate with Patient #4’s endocrinologist to inform the endocrinologist Patient #4 received home health care to assist her with monitoring her blood glucose and administering Humalog, Lantus and Ozempic or Patient #4’s refusal to have SN come three times a day. 2. The clinical record for Patient #2 was reviewed on 1/3/24. The plan of care for the certification period dated 12/10/23 to 2/7/24 revealed a start of care date of 12/10/23; diagnoses included spinal stenosis, hypertension, hyperlipidemia and chronic pain syndrome. Plan of care orders included SN visits one time every 60 days with 3 PRN visits for assessment including vital signs, hydration and dietary status and medication reconciliation. Physical therapy (PT) evaluation and treatment to assess Patient #2’s functional status and home environment and to improve Patient #2’s safety and functional independence. Occupational therapy (OT) evaluation and treatment to assess Patient #2’s functional independence with activities of daily living. a) Physical Therapist #4 failed to communicate with Patient #2’s physician in a timely manner when Patient #2 requested to delay her PT evaluation. Review of Patient #2’s record revealed PT #4 documented on 12/12/23 at 12:14 p.m. PT #4 spoke with Patient #2 regarding her upcoming PT evaluation. Patient #2 requested to change her PT evaluation to 12/19/23 at 1:30 p.m. due to a scheduling conflict with her original PT appointment. Review of Patient #2’s record revealed PT #4 completed a PT evaluation with Patient #2 on 12/19/23 and documented care coordination with OT. Review of Patient #2’s record revealed a therapy order which stated PT #4 attempted to contact Patient #2’s physician on 12/20/23 at 3:13 p.m. for approval of PT with the following frequency order: zero times week one, one time a week for one week, zero times a week for one week, and two times a week for four weeks starting the week of 12/10/23. The therapy order stated “if no phone call is returned, fax will be sent over to the doctors office for approval.” This order was not signed by Patient #2’s physician by the survey exit. During an interview on 1/4/24 at 2:52 p.m., PT #4 stated he received orders to evaluate Patient #2 on 12/8/23. Patient #2, on 12/12/23, requested to delay her PT evaluation until 12/19/23. PT #4 acknowledged the first time he attempted to contact Patient #2’s physician to inform him of Patient #2’s request to delay her PT evaluation until 12/19/23 was on 12/20/23 and he did not speak to Patient #2’s physician or office. PT #4 stated instead he left a voicemail regarding the delayed start of care and request for frequency orders. PT #4 stated he was told he had thirty days to complete an evaluation upon receiving an order for a PT evaluation. PT #4 stated in the future he would ensure to contact an ordering physician the day a patient requested to delay an order to ensure he complied with regulations. During an interview on 1/4/24 at 3:11 p.m., the administrator stated he was not aware PT #4 failed to notify Patient #2’s physician of his delay in completing Patient #2’s PT evaluation. The administrator stated he was aware regulation required PT #4 to communicate this delay to Patient #2’s physician.”