Liberty Home Care

“Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient’s status at the time of assessment. This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] question N0415 [high risk medications] was answered incorrectly for 3 [#7, 8, 13] of 13 records. The findings included: The policy, Comprehensive Assessment/OASIS Collection, Encoding, and Transmission [01/2025] was provided by the agency administrator on 03/25/26 at 11 am. The policy stated, “...The auditor/clinical manager/administrator completes a clinical record review of the OASIS...looking for inconsistencies and discrepancies. This will help ensure the accuracy of the OASIS data...” 1. Patient # 7 had a Start of Care [SOC] date of 02/16/25 with an admitting diagnosis of encounter for change or removal of surgical dressings and type 2 diabetes mellitus without complications. Review of the Plan of Care [POC] for the certification period 02/16/26-04/16/26 included an order for Aspirin [anti-platelet] 81 mg daily. Review of the clinical record revealed RN # 9 completed the SOC OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] on 02/16/25. Review of the OASIS documentation revealed the RN failed to capture the use of an anti-platelet when answering OASIS question N0425 [high risk medications]. During an interview with the agency administrator on 03/25/26 at 11 am it was confirmed the OASIS was inaccurate. 2. Patient # 8 had a Start of Care [SOC] date of 02/10/26 with admitting diagnoses of encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus with diabetic neuropathy [elevated blood sugars damage nerves], and type 1 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care [POC] for the certification period 02/10/26-04/10/26 revealed an order for Tramadol [opioid] 50 mg every 8 hours as needed for pain. Review of the clinical record revealed RN # 9 completed the SOC OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] on 02/10/25. Review of the OASIS documentation revealed the RN failed to capture the use of an opioid when answering OASIS question N0425 [high risk medications]. During an interview with the agency administrator on 03/25/26 at 11 am it was confirmed the OASIS was inaccurate. 3. Patient # 13 had a Start of Care [SOC] date of 09/09/25 with an admitting diagnosis of hypertensive kidney disease with stage 5 kidney disease [high blood pressure damages vessels in kidneys]. The Plan of Care [POC] for the certification period 09/09/25-11/07/25 included an order for Aspirin [anti-platelet] 81 mg daily. Review of the clinical record revealed RN # 9 completed the SOC OASIS [The Outcome and Assessment Information Set – patient specific, standardized assessment used in home health] on 09/09/25. Review of the OASIS documentation revealed the RN failed to capture the use of an anti-platelet when answering OASIS question N0425 [high risk medications]. During an interview with the agency administrator on 03/25/26 at 11 am it was confirmed the OASIS was inaccurate.”

“Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This Standard is not met as evidenced by: Based on agency policy, clinical record review, and staff interviews, the home health aide care plan failed to include necessary safety measures for 3 of 3 patients who received aide services [ # 6, 7, 8]. The findings included: The policy, Home Health Aide Care Plan and Documentation [01/2025], was provided by the agency administrator on 03/25/26 at 12:30 pm. The policy stated, “...The registered nurse or other appropriate skilled professional develops the home health aide care plan...completing all parts and providing the aide with all necessary information to carry out his/her duties safely...” 1. Patient # 6 had a Start of Care date of 02/23/26 with an admitting diagnosis of encounter for orthopedic aftercare following surgical amputation and type 2 diabetes mellitus with diabetic chronic kidney disease [elevated blood sugars damage vessels in the kidneys]. Review of the Plan of Care [POC] for the certification period 02/23/26-04/23/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks; home health aide 2 times a week for 4 weeks, 1 time a week for 2 weeks. The POC also included orders for Aspirin [anti-platelet] 81 mg daily and Apixaban [anti-coagulant] 5 mg 2 times a day. Review of the home health aide care plan completed by RN # 5 on 02/23/26 revealed no bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] included in the safety measures section of the aide care plan. During an interview with the administrator on 03/25/26 at 11 am, the administrator confirmed the safety precautions should always include bleeding and diabetic precautions to alert the home health aide. 2. Patient # 7 had a Start of Care date of 02/16/25 with an admitting diagnosis of encounter for change or removal of surgical dressings and type 2 diabetes mellitus without complications. The patient did receive medications, including insulin, for diabetes. Review of the Plan of Care [POC] for the certification period 2/16/26-4/16/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 7 weeks; home health aide 1 time a week for 1 week, 2 times a week for 5 weeks, 1 time a week for 2 weeks. Review of the home health aide care plan revealed no mention of bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] in the safety precautions section. During an interview with the administrator on 03/25/26, the administrator confirmed the aide should be made aware of the possible safety concerns. 3. Patient # 8 had a Start of Care date of 02/10/26 with admitting diagnoses of encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus with diabetic neuropathy [elevated blood sugars damage nerves], and type 1 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care [POC] for the certification period 02/10/26-04/10/26 included orders for SN [skilled nursing] 2 times a week for 2 weeks, 1 time a week for 2 weeks, 1 time every other week for 5 weeks; home health aide 1 time a week for 1 week, 2 times a week for 5 weeks, 1 time a week for 2 weeks. The POC also revealed the patient was ordered insulin for the diabetes mellitus, and an anti-platelet. Review of the clinical record revealed RN # 5 completed the aide care plan on 2/10/26. Review of the aide care plan revealed bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] nor diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] were included in the safety measures section of the care plan. During an interview with the administrator on 3/25/26 at 11 am the administrator confirmed this information should have been included on the aide care plan.”

“Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient’s mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient’s risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This Element is not met as evidenced by: Based on agency policy, direct observations, clinical record review, and interviews with patient/caregivers and staff the Plan of Care [POC] failed to include current/correct medications for 3 of 5 patients who received home visits [#1, 2, 3];and failed to include appropriate safety measures for 8 of 13 records reviewed [ #2, 3, 4, 6, 7, 8, 11 and 13]; and failed to include updated/appropriate goals and or interventions for 5 of 13 charts [#1, 2, 3, 8, 10]. The findings included: The policy, Medication Profile and Medication Reconciliation [01/2025], was provided by the agency director on 03/25/26 at 08:34 am. The policy stated, “...A current listing of all medications the patient is using is maintained in the clinical record at all times...” The policy, Care Planning: Initial Care Plan and Updates to the Plan of Care [03/2024], was provided by the agency director on 03/25/26 at 08: 34 am. The policy stated, “...Each patient will receive an individualized written plan of care...The plan of care also included documentation of the following...Specific patient care orders, including verbal orders, interventions and treatments for each discipline...All current prescription and over the counter medications...Safety measures to minimize the risk of harm to the patient and protect against injury...Realistic, measurable goals/outcomes for each identified problem...” 1A. Patient # 1 had a Start of Care date of 02/12/24. Review of the Plan of Care [POC] for the certification period 02/01/26-04/01/26 revealed a primary diagnosis of pressure ulcer of right buttock, stage 2 [ partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow, open ulcer or a ruptured blister]. Further review of the POC revealed orders for SN [skilled nursing] 1 time a week for 9 weeks and “...SN to perform medication review each skilled nursing visit and reconcile medications as indicated...” On 03/24/26 at approximately 09:30 am a joint visit was made with RN # 1. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: Diclofenac Sodium [topical gel used for pain] 1% External Cream daily for pain was listed on the medication profile. The medication had a start date of 11/28/24. During an interview with the patient and the cg [caregiver] after the joint visit, the patient reported, “We never did pick that up from the pharmacy. I never have used it.” Furosemide 20 mg [fluid medication] take 1 tablet PRN [as needed] was listed on the medication profile. There was no start date on the medication profile. During the interview with the patient he reported, “I take that every day. “ The patient presented a bottle of Equate Arthritis [over the counter pain relief] 650 mg. The medication was not listed on the medication profile. The patient reported taking the medication routinely every 8 hours. Naproxen 500 mg [non-steroidal] 1 tablet two times a day was listed on the medication profile. There was no start date noted. During the interview with the patient, he reported not taking the medication since “October or November of last year.” The patient presented a bottle of Pregabalin 200 mg [used for nerve pain] take 1 tablet three times a day. The date on the medication bottle was 03/19/26. The Pregabalin was not listed on the medication profile. Vitamin D 25 MCG 50,000 units [supplement] 1 capsule each week was listed on the medication profile. The patient reported, “I haven’t taken that in God knows how long.” During an interview with RN # 1 on 03/24/26 after the visit, the RN confirmed the medications in the home did not match the POC. 1B. Patient # 1 had a Start of Care [SOC] date of 02/12/24. Review of the Plan of Care [POC] for the certification period 02/01/26-04/01/26 revealed a primary diagnosis of pressure ulcer of right buttock, stage 2 [partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow, open ulcer or a ruptured blister]. Further review of the POC revealed the same goals on the POC as the SOC. The goals included: “Patient/caregiver will be able to verbalize signs of infection and report and demonstrate proper infection precautions by 2 weeks”. “Patient/caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. “Patient/caregiver demonstrate ability to effectively manage medication regimen by 2 weeks”. During an interview with the agency administrator on 03/25/26 at 11 am the administrator stated, “The goals are auto generated in the system and the clinicians have to update them.” 2A. Patient # 2 had a Start of Care date of 12/16/25. Review of the Plan of Care [POC] for the certification period 02/14/26-04/14/26 revealed a diagnosis of pressure ulcer of right heal, unstageable [full-thickness skin and tissue loss where the actual depth is hidden by slough (yellow, tan, gray, green, or brown) or eschar (tan, black, or brown)]. The POC included orders for SN [ skilled nursing] 0 times a week for 1 week, 2 times a week for 8 weeks, 1 time a week for 1 week and “...SN to perform medication review each skilled nursing visit and reconcile medications as indicated...” On 03/24/26, at approximately 10:30 am, a joint visit was made with RN # 2. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Potassium Chloride 20 meq [supplement] take 1 tablet daily with a start date of 12/01/25. During an interview with the caregiver, the caregiver reported the patient no longer took the potassium. The medication profile listed Sertraline 100 mg [antidepressant] take 1 tablet daily. During the interview with the caregiver, she reported the patient took 50 mg-3 tablets each day. During an interview with RN # 2 after the visit, the RN confirmed the medications listed on the POC were incorrect. 2B. Patient # 2 had a Start of Care date of 12/16/25. Review of the Plan of Care [POC] for the certification period 02/14/26-04/14/26 revealed a diagnosis of pressure ulcer of right heal, unstageable [full-thickness skin and tissue loss where the actual depth is hidden by slough (yellow, tan, gray, green, or brown) or eschar (tan, black, or brown)]. Further review of the POC included an order for Apixaban [anti-coagulant] 5 mg. Take 1 tablet BID [two times a day]. The start date for the medication was listed as 10/15/25. The POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 2C. Patient # 2 had a Start of Care date of 12/16/25. Review of the Plan of Care [POC] for the certification period 02/14/26-04/14/26 revealed a diagnosis of pressure ulcer of right heal, unstageable [full-thickness skin and tissue loss where the actual depth is hidden by slough (yellow, tan, gray, green, or brown) or eschar (tan, black, or brown)].Further review of the POC included the following goal which was carried over from the previous certification period: “Patient/caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. During an interview with the agency administrator on 03/25/26 at 11 am the administrator stated, “The goals are auto generated in the system and the clinicians have to update them.” 3A. Patient # 3 had a Start of Care date of 10/17/25. Review of the Plan of Care [POC] for the certification period 02/14/25-04/14/25 included orders for PT [physical therapy] 1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 5 weeks. On 03/24/26 at approximately 12:15 pm a joint visit was made with PTA [physical therapy assistant] # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Amlodipine 10 mg [blood pressure] daily. The patient presented a bottle of Amlodipine 2.5 mg and advised this was the current dose. He reported using the 2.5 mg for “a while.” The medication profile listed Aspirin [anti-platelet] 81 mg. During the interview with the patient he reported he no longer used the aspirin. He reported stopping it about “a month ago or so.” The medication profile listed Losartan Potassium -HCTZ [blood pressure with fluid medication] 50-12.5 mg daily. During the interview with the patient he stated, “I don’t take that blood pressure pill anymore.” The medication profile listed Metformin 1000 mg [diabetic medication] 1 tablet two times a day. During the interview with the patient he stated,” I take 500 mg two times a day”. The patient presented a bottle of Crestor [cholesterol medication] 5 mg daily with a start date of 12/29/25. This medication was not on the medication profile. The patient presented a bottle of Apixaban [blood thinner] 5 mg with instructions to take the medication 1 tablet 2 times a day. This medication was not listed on the medication profile. During an interview with PTA # 3 after the visit, it was confirmed the POC did not include all the current/correction medications. 3B. Patient # 3 had a Start of Care date of 10/17/25. Review of the Plan of Care [POC] for the certification period 02/14/25-04/14/25 revealed a diagnosis of infection following a procedure, superficial incisional surgical site and displaced fracture of anterior column of right acetabulum [hip socket]. On 03/24/26 at approximately 12:15 pm a joint visit was made with PTA [physical therapy assistant] # 3. During the visit a medication review was conducted using a medication profile provided by the agency. The patient presented a bottle of Apixaban [blood thinner] 5 mg with instructions to take the medication 1 tablet 2 times a day [not on the POC]. Review of the POC revealed the safety precautions did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures 3C. Patient # 3 had a Start of Care date of 10/17/25. Review of the Plan of Care [POC] for the certification period 02/14/25-04/14/25 revealed a diagnosis of infection following a procedure, superficial incisional surgical site and displaced fracture of anterior column of right acetabulum [hip socket]. Further review of the POC revealed orders for SN [skilled nursing] and PT [physical therapy]. Review of the POC revealed goals for OT [occupational therapy]. Review of the clinical record revealed the patient was discharged for OT services on 02/11/26 with goals met. During an interview with the agency administrator on 3/25/26 at 11 am, the director reported, “OT must have forgotten to go in and remove the goals from the new POC.” 4. Patient # 4 had a Start of Care date of 03/09/26 with an admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [high blood sugar]. Review of the Plan of Care [POC] for the certification period 03/09/26-05/07/26 included orders for Lantus [insulin] 15 units each am, Aspirin [anti-platelet] 81 mg each day, and Apixaban [anti-coagulant] 2.5 mg 2 times a day. Further review of the POC revealed no bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores] listed in the safety section of the POC. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 5. Patient # 6 had a Start of Care date of 02/23/26 with an admitting diagnosis of encounter for orthopedic aftercare following surgical amputation. Review of the Plan of Care [POC] for the certification period 02/23/26-04/23/26 included an order for Aspirin [anti-platelet] 81 mg each day and Clopidogrel [anti-platelet] 75 mg each day. Further review of the POC revealed no safety measures related to bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 6. Patient # 7 had a Start of Care date of 02/16/25 with an admitting diagnosis of encounter for change or removal of surgical dressing. Review of the Plan of Care [POC] for the certification period 02/16/26-04/16/26 included orders for Aspirin [anti-platelet] 81 mg daily and Apixaban [anti-coagulant] 5 mg two times a day. Review of the safety precautions on the POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 7. Patient # 8 had a Start of Care date of 02/10/26 with admitting diagnoses of encounter for change or removal of surgical wound dressing, type 1 diabetes mellitus with diabetic neuropathy [elevated blood sugars damage nerves], and type 1 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care [POC] for the certification period 02/10/26-04/10/26 included orders for Aspirin [anti-platelet] 81 mg each day and Plavix [anti-platelet] 75 mg each day. Further review of the POC revealed bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs wearing shoes indoors, and reducing fall risks] were not included on the POC. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 8A. Patient # 11 had a Start of Care date of 12/05/24. Review of the Plan of Care for the certification period 02/03/25-04/03/25 revealed the patient was ordered Eliquis [anti-coagulant] 5 mg two times a day, Humalog Insulin [diabetic medication] three times a day by sliding scale, and Jardiance [diabetic medication] 10 mg daily. The POC also indicated the patient had an active diagnosis of type 2 diabetes mellitus with other neurological complications. Further review of the POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs wearing shoes indoors, and reducing fall risks] wearing shoes indoors, and reducing fall risks] or diabetic precautions [precautions used to help prevent complications caused by diabetes which may include monitoring blood sugar, maintaining a healthy weight, and checking feet regularly for sores]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 8B. Patient # 11 had a Start of Care date of 12/5/24. Review of the Plan of Care for the certification period 2/3/25-4/3/25 revealed an active diagnosis of pressure ulcer of left heel, stage 2 [partial-thickness skin loss involving the epidermis and/or dermis, presenting as a shallow, open ulcer or a ruptured blister]. Review of the goals on the POC included : “Patient/caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. During an interview with the agency administrator on 3/25/26 at 11 am, the administrator confirmed this goal should have been resolved during the last episode and not carried over to the new POC. 9. Patient # 13 had a Start of Care date of 09/09/25 with an admitting diagnosis of hypertensive kidney disease with stage 5 kidney disease [high blood pressure damages vessels in kidneys]. Review of the Plan of Care [POC] for the certification 09/09/25-11/07/25 revealed the POC included an order for Aspirin [anti-platelet] 81 mg each day. Review of the safety precautions on the POC did not include bleeding precautions [precautions essential for individuals on blood thinners, with low platelets, or bleeding disorders to prevent injury and control bleeding. Key actions include using a soft toothbrush, electric razors, avoiding NSAIDs [nonsteroidal anti-inflammatory] drugs, wearing shoes indoors, and reducing fall risks]. During an interview with the agency administrator on 03/25/26 at 11 am, the administrator confirmed the POC failed to include appropriate safety measures. 10. Patient # 10 had a Start of Care date of 11/09/24. Review of the Plan of Care [POC] for the certification period 03/19/25-05/17/25 revealed the following nursing goal, “Patient/Caregiver will demonstrate understanding of individual emergency preparedness plan by 2 weeks”. Review of the previous POC revealed the same goal. During an interview with the agency administrator on 03/25/26 at 11 am the director stated, “We have told our clinicians to resolve goals as needed, but they just pull them over to the new episode.””

“Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This Element is not met as evidenced by: Based on direct observation, clinical record review, and staff interviews, the registered nurse failed to provide proper diabetic teaching regarding diet for 1 of 1 patient who was newly admitted with a diagnosis of diabetes mellitus [#5]. The findings included: Patient # 5 had a Start of Care date of 03/09/26 with admitting diagnosis of type 2 diabetes mellitus with hyperglycemia [elevated blood sugars]. Review of the Plan of Care for the certification period 03/09/26-05/07/26 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 6 weeks and “SN to instruct patient on self-management program to include...dietary measures...blood sugar monitoring, hypo/hyperglycemia management and long-term complications...” On 03/24/26 at approximately 1:30 pm a joint visit was made with RN # 6. During the visit, the RN assessed the patient’s water intake. The patient stated, “I don’t drink water...I drink mountain dew and pepsi...” The RN asked the patient if he drank diet sodas. The patient replied, “Do I look like a diet...” The conversation ended. The RN failed to educate the patient on complications related to using soda and did not discuss the effects this would have on the disease process or blood sugar readings. During an interview with the agency administrator on 3/25/26 at 11 am the administrator confirmed the RN should have handled this education better.”