Regional Nursing Services Mgmt., Inc.

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to code and electronically transmit completed OASIS (Outcome and Assessment Information Set) assessments to the CMS (Center for Medicare and Medicaid) system within thirty days of completing the assessment of the beneficiary for 19 of 225 (8.44%) records submitted. This failure prevented the patient’s data from being made available to Center for Medicare and Medicaid (CMS) for analysis to identify agency performance levels in the provision of patient care. The findings included: Record review of IQIES “Home Health Error Summary by Agency” report for 08/01/2024 - 08/18/2025generated from the CMS national data system during presurvey preparation on 08/18/25 revealed Agency had submitted and processed 225 assessments. The report also revealed the Agency had 19 assessments with error -3330 indicating those records were submitted after the 30th date of the M0090 (assessment) date, which equaled to 8.44% of the total assessments submitted in error. In an interview with the DON on 06/26/25 at 10:00 am Surveyor presented the above findings. DON stated she and the Alt Adm were responsible for encoding and transmitting OASIS information to CMS. DON did not dispute the errors and are aware of the OASIS late submissions. DON confirmed that the process was1) RN completes OASIS, 2) RN sends to QA, 3) QA reviews and makes corrections, which are sent back to RN, 4) RN make correction and sends it back to QA, 5) OASIS is finalized and exported. Surveyor asked why they had late submissions for their Oasis. DON stated, “It’s been a transition that we are working on due to an employee leaving. Sometimes the oasis is completed late by the RN as it is a process, and we have to remind the RNs to send them in a timely manner. It’s a process of going back and forth with the RNs and it takes a while.” Surveyor further asked how late Oasis submissions can affect patient care. Adm confirmed it may affect their insurance due to late oasis submissions, however, does not affect care provided by the agency. Record review of the Agency’s policy manual contained a policy titled, “Timelines IM.10”, with a revision date of 12/01/14, quoted in part, “Policy: Agency will ensure timely provision of care and services to meet the patient’s needs in compliance with all federal and state laws and regulations…Procedure…Completed and encoded OASIS date will be transmitted via electronic communication software…It will be transmitted to CMS OASIS contractor within 30 days of the M0090 date.” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 08/26/25.”

“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 record review, observation, and interview the agency failed to ensure staff consistently followed infection control policies and procedures including the prevention of the spread of infectious and communicable disease related to hand hygiene, glove use, and proper handling of reusable supplies during home visits for 3 of 5 active Patients (Patient #1, 2, and 3) reviewed for infection control in that: LVN A failed to follow proper infection control procedures and policies while conducting home visits with patients #1, #2, and #3. 1.) Missed opportunities for glove changes/ Proper use of PPE (gloves). a) LVN failed to change or remove her gloves before cleaning her reusable supplies. b) LVN failed to remove gloves before entering her nursing bag to prevent cross contamination. c) LVN did not clean supplies with gloves on. 2.) Missed opportunities for hand hygiene. a) LVN failed to hand sanitize or hand wash before cleaning her reusable supplies b) LVN failed to use hand sanitizer or handwashing in between glove changes and post completion with patient. This deficient practice could place Patients #1, #2, #3, as well as other active patients, at risk for cross-contamination, increased infections, and potential worsening of their conditions and comorbidities (medical conditions that coexist along with primary diagnosis). The findings included: Record review of the Agency’s policy manual contained a policy titled, “Infection Control Plan 2020”, with a revision date of 03/15/19, quoted in part, “Responsibility…all personnel…are responsible for preventing and controlling infection control activities….Infection control activities…CDC, OSHA, Texas department of State health Services…the healthcare provider plans to minimize, reduce or eliminate the risk of infection by the following Infection control activities as related to: bag technique…Durable Medical Equipment, Devices and supplies…Precautions—Standard, hand hygiene, personal protective equipment…Implementation: Bag technique, the healthcare provider will ensure use of clean medical supplies or devices on patients, including…using the bag technique…When visit is completed…discard of PPE…clean equipment using disinfectant…perform hand hygiene, place supplies/equipment in the bag…Hand hygiene…procedures… Indications for hand hygiene. Always perform hand hygiene in the following situations…after touching the patient, even if gloves are worn…after glove removal…CDC guidelines…Personal Protective Equipment…Use of PPE…Perform hand hygiene before and immediately after removing gloves…” Record review of the Agency’s policy manual contained a policy titled, “Infection Control Program IC.1”, with a revision date of 04/01/15, quoted in part, “To outline the policies and procedures for an infection control program which applies to patients, staff, and care provided. The program improves patient health outcomes…and reduction of risks of infections in patients and staff….CDC guidelines, Communicable Disease Prevention and Control Act…current federal/state/local laws and regulations…Geriatric patients, by the nature of their age, diagnosis, or the treatment(s) ordered have an increased risk to develop genitourinary, respiratory, and integumentary infections. Record review of the Agency’s policy manual contained a policy titled, “Hand hygiene IC.3”, with a revision date of 09/01/14, quoted in part, “To ensure patient/client care staff practice proper hand hygiene techniques…to aid in the prevention and spread of infection per CDC guidelines…All agency staff providing patient/client care will observe proper hand hygiene techniques…following each patient/client contact even when gloves are worn, after removing gloves…after contact with inanimate objects or medical equipment…before handling medication…” Record review of the Agency’s policy manual contained a policy titled, “Cleaning and Management of Supplies, Toys, and Equipment IC.4”, with a revision date of 09/01/14, quoted in part, “To ensure the proper cleaning and management of supplies…and equipment is maintained by agency staff…Procedure…The cleaning and management of supplies and equipment will be handled according to…the guidelines in the exposure control plan.” Record review of the Agency’s policy manual contained a policy titled, “Exposure Control Plan IC.2”, with a revision date of 11/01/15, quoted in part, “To establish agency programs that include policies and procedure for the protection of patients/clients and staff from exposure…pathogens…methods of implementation…standard precautions…proper hand hygiene, gloves must be worn…when reasonable potential for contamination…staff responsibilities…to appropriately implement the PPE…and work practice controls to decrease risk of exposure…procedure for cleaning and management of supplies and equipment…Nurse/HHA bag…prevent contamination by washing hands prior to entering bag and by not placing contaminated supplies back inside the bag. Record review of the Agency’s policy manual contained a policy titled, “Agency Statement” with no date, quoted in part, “Agency will participate and be in compliance with federal, state, and local laws and regulations…Agency utilizes the Lippincott for clinical procedures…” 1. Review of Patient #1 “Home Health certification and plan of care” documented a 85-year-old geriatric (older adult population aged 65 or older) male with primary diagnosis of Hypertensive heart disease with heart failure (serious condition that occurs when the heart cannot pump enough blood), Acute chronic diastolic heart failure (heart’s left ventricle becomes stiff and cannot fill properly, leading to symptoms like shortness of breath and fatigue), Mixed hyperlipidemia (elevated levels of both cholesterol and triglycerides in the blood), Elevated prostate specific antigen (may be a sign of prostate cancer or non-cancerous conditions), Prediabetes (condition where blood sugar levels are higher than normal but not high enough to be diabetes), alcohol abuse, Obesity (disease involving having too much body fat), and, Presence of xenogenic heart valve (heart valve from animal tissues, commonly used in cardiac surgeries to replace damaged or diseased valves). The form also documented a start of care as 07/24/25 and a “current episode” or certification period as 07/24/25-09/21/25 with skilled nurse visits once a week times one week, two times a week times one week, and once a week times seven weeks. Safety: Standard/Infection control. An observation was made of LVN A performing a home visit with patient #1 on 08/21/25 at 1:30 pm. Brief introductions were made, and consent was signed by patient #3. LVN A and surveyor proceeded into patient’s home, introductions were made, and consent was signed by patient #1. LVN A placed first barrier on a chair and her nursing bag on top of the barrier. LVN A washed her hands with soap and water per CDC guidelines. LVN A placed a second barrier on top of table and donned (put on) gloves, removed stethoscope, thermometer, and blood pressure cuff from nursing bag and placed them on top of second barrier. LVN A checked temperature of patient, then manually checked his blood pressure (measures the pressure of circulating blood against the walls of blood vessels) on his left upper arm. LVN A then proceeded to auscultate (listening to sounds from the heart, lungs, or other organs) his heart, lungs, and all four quadrants of his abdomen. Patient confirmed his last bowel movement was on 08/20/25 and had no issues going to the bathroom. LVN A assessed bowel sounds. LVN A placed stethoscope, thermometer, and blood pressure cuff on top of second barrier. LVN A checked patient’s bilateral (both) legs and feet. LVN A asked patient about his pain, patient confirmed 3/10 pain to right hip. Patient further confirmed he has no vision problems, dizziness, vomiting/nausea, or any recent falls. LVN A educated patient on medications and did a medication reconciliation. LVN A further educated patient on his blood pressure, cardiac care, diet, and footcare. LVN A began to clean her stethoscope, thermometer, and blood pressure cuff with a disinfectant wipe with the same contaminated gloves she used to assess the patient. LVN A then placed stethoscope, thermometer, and blood pressure cuff into her bag with contaminated gloves still donned. LVN A picked up 2nd barrier from the table, doffed (took off) gloves and placed them into trash can. LVN A then proceeded to pick up her nursing bag and then 1st barrier and placed it in the trash can. Lastly, LVN A sanitized her hands with hand sanitizer. 2. Review of Patient # 2 “Home Health certification and plan of care” documented a 56-year-old female with primary diagnosis of Type II Diabetes Mellitus with hyperglycemia (blood sugar elevates to dangerous levels), hyperlipidemia (blood has too much fat), down syndrome (genetic disorder that occurs when an individual has an extra full or partial chromosome), developmental disorder of scholastic skills (impair a person’s ability to acquire essential academic skills such as reading, writing, and arithmetic), hypothyroidism (thyroid gland does not produce enough hormones), hyperuricemia (high uric acid in the body), insomnia (lack of sleep or no sleep), mental and behavioral disorders, and use of oral hypoglycemic drugs (medication that lowers blood sugar levels). The form also documented a start of care as 03/21/25 and a “current episode” or certification period as 07/19/25-09/16/25 with skilled nurse visits once a week times seven weeks, twice a week times one week, and three PRN visits. Safety: Standard precautions/Infection control. An observation was made of LVN A performing a home visit with patient #2 on 08/21/25 at 2:00 pm. Brief introductions were made, and consent was signed by patient #2. LVN A and surveyor proceeded into patient’s home, introductions were made, and consent was signed by patient #2. LVN A placed first barrier on the countertop and then her nursing bag onto of the barrier. LVN A washed her hands with soap and water per CDC guidelines. LVN A placed second barrier on the left side of her nursing bag. LVN A removed thermometer, stethoscope, blood glucose machine and blood pressure cuff on second barrier. Donned gloves. LVN A checked patient’s temperature and blood pressure manually. LVN A auscultated heart, lungs, and all four quadrants of her abdomen. LVN A placed thermometer, stethoscope, and blood pressure cuff then palpated (examined by touch) abdomen. LVN A set-up supplies to check the blood glucose for patient. LVN A cleansed left middle finger with an alcohol wipe, squeezed finger, a drop of blood appeared on the left middle finger, LVN A grabbed glucose machine, placed a drop of blood on strip and received a reading of 130 mg/dl (milligrams per deciliter) (normal level). LVN A placed lancet in a non-puncture plastic container inside of the outer pocket of nursing bag. LVN A then began to cleanse thermometer, stethoscope, blood pressure cuff, lancet device, and glucometer machine with a disinfecting wipe using the same contaminated gloves used to assess patient and check blood glucose (measuring the level of sugar in the blood). LVN A placed supplies into her nursing bag with contaminated gloves on. LVN A picked up second barrier and threw it into trash can. LVN A further assessed patient’s bilateral legs and feet with the same contaminated gloves used to assess patient, check blood glucose, and disinfect supplies. Missed opportunities for glove change. LVN A doffed gloves and placed them into trash can. LVN donned new gloves and completed a medication review. LVN A did not use hand sanitizer nor hand wash with soap and water in between glove change. LVN doffed gloves and threw them in trash can. LVN A washed hands with soap and water per CDC guidelines. 3. Review of Patient #3 “Home Health certification and plan of care” documented a 75-year-old geriatric female with primary diagnosis of Essential hypertension (when the force of blood pushing against your artery walls is consistently too high), prediabetes (condition where blood sugar levels are higher than normal but not high enough to be diabetes), schizophrenia (severe mental disorder with significant impairments on how reality is perceived), developmental disorder of scholastic skills (impair a person’s ability to acquire essential academic skills such as reading, writing, and arithmetic), severe intellectual disabilities (significant limitations in cognitive functioning and adaptive behavior requiring extensive support for daily living), anxiety disorder (uncontrollable feelings of fear), hyperlipidemia (blood has too much fat), BMI 28.0-28.9 adult (overweight), and long term use of NSAIDs (pain medications used to treat muscle and joint pain, alleviate inflammation). The form also documented a start of care as 03/21/25 and a certification period as 07/19/25-09/16/25 with skilled nurse visits once a week times seven weeks, two times a week times one week, and three as needed visits. Safety: Standard precautions/Infection control. An observation was made of LVN A performing a home visit with patient #3 on 08/21/25 at 2:30 pm. Brief introductions were made, and consent was signed by patient #3. LVN A and surveyor proceeded into patient’s home, introductions were made, and consent was signed by patient #3. LVN A washed hands with soap and water per CDC guidelines. LVN A placed a second barrier on the left side of her nursing bag and removed supplies then proceeded to place them onto the barrier. Donned (put on) gloves. LVN A assessed oxygen with pulse oximetry (measures oxygen in our blood), temperature, and checked blood pressure manually (measures the pressure of circulating blood against the walls of blood vessels). LVN A auscultated (listening to sounds from the heart, lungs, or other organs) heart, lungs, and all four quadrants of her abdomen. Palpated (examine by touching body) abdomen. Assessed/educated patient on diet, falls, bowel movements, and sleep. LVN A assessed bilateral legs/feet. LVN A doffed (took off) gloves and threw them into trash can. Donned new gloves. LVN A did not use hand sanitizer or hand wash with soap and water after removal of the soiled gloves. LVN A did medication reconciliation for patient #3. Doffs gloves. Trash can. No use of hand sanitizer or hand washing with soap and water. LVN A cleansed supplies with disinfecting wipe and places them in nursing bag. LVN A did not have gloves on while cleaning supplies or sanitize hands prior to cleaning supplies. LVN A throws away barrier and places into trash can. LVN A grabbed her personal soap bottle from the sink and placed into her nursing bag. LVN A picks up barrier and throws in trash. LVN A did not use hand sanitizer or hand washing with soap and water post home visit. In an interview with the Alt Adm and DON on 08/22/25 at 10:45 am, surveyor presented the above infection control findings during home visits for patients #1, #2, and #3 which included the following: Missed opportunities for glove changes/Proper use of PPE and missed opportunities for hand hygiene. Alt Adm and DON agreed to these infection control findings and further confirmed clinical staff were to use infection control precautions such as handwashing, use of hand sanitizer, appropriate use of PPE, and clean bag technique to prevent risk of infection and cross-contamination at every home visit. DON stated Lippincott was used at the agency for clinical procedures and is a part of their policy. Alt Adm and DON revealed clinical staff are trained on infection control precautions upon hire, mid-year, and annually. DON further revealed that these infection control findings could place patients at risk for infection or cross-contamination. Subsequently in an interview with LVN A on 08/22/25 at 4:20 pm, surveyor presented the above infection control findings during home visits for patients #1, #2, and #3 which included the following: Missed opportunities for glove changes/ Proper use of PPE (gloves) and missed opportunities for hand hygiene. LVN A agreed to these infection control findings and further confirmed she was trained upon hire, annually, and has refreshers during conference meetings with the agency. LVN A confirmed that the policy for bag technique was not to reach into your bag with gloves on and to disinfect supplies after each patient. Surveyor asked why she reached into her bag with gloves on and did not properly disinfect equipment. LVN A stated, “I was nervous.” LVN A confirmed the policy for PPE, the use of gloves was to change your gloves when changing sites and change your gloves if you touch your face or other contaminated objects. Surveyor asked why she used the same gloves used to assess her patients to clean her supplies for patients #1 and #2. LVN confirmed due to nervousness during the home visit, she forgot to change her gloves and had concerns about potentially making an error that might reflect negatively on the agency. LVN A confirmed the policy for handwashing and use of hand sanitizer should be used before and after contact with a patient and in between glove changes. Surveyor asked why she did not use hand sanitizer after the removal of her gloves or after the completion of the home visit for patient #3. LVN confirmed she may have missed it. LVN A considers these findings to be an infection control issue, and these findings can put others at risk for infection and can create cross-contamination between patients. Review of Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Blood glucose monitoring” revision date 11/27/22 contains the following in part: A blood glucose meter (glucometer) measures the concentration of glucose in a patient’s blood…Implementation…perform hand hygiene, put on gloves…Turn on the blood glucose meter, and insert a blood glucose test strip according to the manufacturer’s instructions…To collect a blood sample from the patient’s fingertip…After collecting the blood sample…discard supplies…Remove and discard your gloves and, if worn, other personal protective equipment. Perform hand hygiene…” Review of Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Bag technique, home care” revision date 05/19/22 contains the following in part: “Bag technique is a process used by home health care workers to prevent the transmission of microorganisms that may be present on the outside or the inside of the bag. Bag technique involves proper hand hygiene, placement, cleaning, maintenance, and management of equipment and supplies… Perform hand hygiene before entering the bag…Never remove items from the bag wearing gloves. If supplies are needed, remove gloves, perform hand hygiene, and remove additional supplies…” Review of Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Hand Hygiene, home care” revision date 02/19/23 contains the following in part: “Using an alcohol-based hand rub is appropriate for decontaminating the hands…before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care…after removing gloves; and after contact with inanimate objects in the patient’s environment. WHO simplifies points of hand hygiene into five key moments. 1. Before touching a patient 2. Before clean/aseptic procedure 3. After body fluid exposure 4. After touching a patient 5. After touching patient surrounding”. Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Standard precautions, home care” revised date 08/18/22 contains the following in part: “The Centers for Disease Control and Prevention (CDC) developed standard precautions to protect against the transmission of infection… Standard precautions include hand hygiene, appropriate use of personal protective equipment (PPE), and proper handling of potentially contaminated items, including patient equipment, items in the environment, sharps, and specimens…. Perform hand hygiene before and after patient care; before putting on and after removing gloves; when moving from a contaminated boy site to a clean body site; after contact with inanimate objects in the patient’s environment… Change your gloves and perform hand hygiene if your gloves become damaged or heavily soiled and when moving from a contaminated to a clean site during patient care to avoid cross-contamination…” Review Lippincott Advisor & Lippincott Procedures (evidence-based practice information) “Personal protective equipment (PPE), putting on, home care” revised date 08/18/22 contains the following in part: Following standard and transmission-based precautions helps prevent the spread of infection from patient to patient, patient to health care worker, and health care worker to patient… Put on the gloves…Avoid touching your face and your other PPE with your gloved hands during patient care. Also limit touching other surfaces or items to those needed for direct patient care. If your gloves become damaged or heavily soiled, remove them immediately, perform hand hygiene, and put on a new pair of gloves…” Record review of a report from the CDC Morbidity and Mortality Weekly Report titled “Guideline for Hand Hygiene in Health-Care Settings” dated 10/25/22 (RR5116-Front Cover.p32 (cdc.gov), quoted in part, “Recommendations…1. Indications for handwashing and hand antisepsis…C. Decontaminate hands before having direct contact with patients…F. Decontaminate hands after contact with a patient’s intact skin (e.g. when taking a pulse or blood pressure and lifting a patient)…G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled…H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care… J. Decontaminate hands after removing gloves”. Review of OSHA 29 CFR 1910.1030 contains the following in part with a date of 11/03/23: “Personal protective equipment… Gloves. Gloves shall be worn when it can be reasonably anticipated that the employee may have hand contact with blood, other potentially infectious materials, mucous membranes, and nonintact skin …and when handling or touching contaminated items or surfaces.” The agency did not dispute the surveyor’s findings. The agency was afforded the opportunity to provide additional information. No additional information was presented to this surveyor upon exit on 08/26/25.”

“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: (This is a continuing deficiency previously cited G0574 from survey dated 09/23/22.) Based on clinical record review, home visit, and interview, the agency failed to ensure the Plan of Care included medications and treatments for 1 of 5 active patients (patient #3) whose records were reviewed. Patient #3’s plan of care failed to list Citrucel (treats constipation and helps maintain regular bowel movements) 500mg 3 tablets by mouth every day under medications. The failure to include a patient’s prescribed medication on a plan of care places active patients at risk of not receiving necessary treatment as ordered, which could result in unmet medical needs, adverse health outcomes, and comprised quality of care. The findings included: Review of Patient #1 “Home Health certification and plan of care” documented a 75-year-old geriatric female with primary diagnosis of Essential hypertension (when the force of blood pushing against your artery walls is consistently too high), prediabetes (condition where blood sugar levels are higher than normal but not high enough to be diabetes), schizophrenia (severe mental disorder with significant impairments on how reality is perceived), developmental disorder of scholastic skills (impair a person’s ability to acquire essential academic skills such as reading, writing, and arithmetic), severe intellectual disabilities (significant limitations in cognitive functioning and adaptive behavior requiring extensive support for daily living), anxiety disorder (uncontrollable feelings of fear), hyperlipidemia (blood has too much fat), BMI 28.0-28.9 adult (overweight), and long term use of NSAIDs (pain medications used to treat muscle and joint pain, alleviate inflammation). The form also documented a start of care as 03/21/25 and a certification period as 07/19/25-09/16/25 with skilled nurse visits once a week times seven weeks, two times a week times one week, and three as needed visits. Upon further review of the plan of care dated 07/14/25, listed “Medications” as follows: bupropion HCI ER (XL) (antidepressant) 300mg Oral Tablet Extended Release 24 Hour 1 tablet QAM for depression buspirone HCl (used to treat anxiety disorders)10mg Oral Tablet 1 tablet BID PO for anxiety Calcium 500mg + Vitamin D 400mg (support bone health) Oral Tablet 1 tablet BID PO supplement Hydrocortisone 1 % (anti-itching cream) External Cream apply to affect area Q6 hours PRN Topical for itching Ibuprofen 200mg (pain reliever) Oral Tablet 2 tablets every 4 hours PRN PO for pain Latanoprost 0.005 % (used for glaucoma [damage to optic nerve leading to loss of vision] and high eye pressure) Ophthalmic Solution 1 drop both eyes QHS for glaucoma Milk of Magnesia 400 mg/5ml (laxative to relieve constipation) Oral Suspension 2 tablespoons daily PRN for constipation Olanzapine 15 mg (antipsychotic used to improve mood, thoughts, and behavior) 1 tablet QHS PO for schizophrenia Pepto-Bismol 262 mg/15ml (used for upset stomach, indigestion, and diarrhea) Oral Suspension 2 tablespoons every 4 hours PRN for diarrhea Simvastatin 20mg (lower cholesterol levels) Oral Tablet 1 tablet QHS PO for hyperlipidemia Fenofibrate 48mg (lower high cholesterol and triglycerides levels) Oral Tablet 1 table daily PO for hyperlipidemia Losartan Potassium-HCTZ (helps relax blood vessels and reduce fluid retention) 50-12.5mg Oral Tablet 1 tablet every morning PO for hypertension The plan of care failed to include medication Citrucel 500mg 3 tablets by mouth every day under medications. A home visit was conducted with patient #3 and LVN A on 08/21/25 at 2:30 pm. LVN A conducted a medication reconciliation in which Citrucel 500mg 3 tablets by mouth every day was observed in a blister pack dated 07/16/25. LVN A confirmed during the home visit that the medication Citrucel 500mg 3 tablets by mouth every day was not listed on the plan of care dated 07/14/25. Patient #3 unable to be interviewed due to intellectual disabilities. Interview was conducted with the Alt Adm and DON on 08/22/25 at 10:45 am, the DON confirmed that the medication Citrucel 500mg 3 tablets by mouth every day was not listed on the plan of care and that it was an oversight. DON further confirmed with this oversight the agency would not be able to monitor any adverse reactions the patient may have. An interview was conducted with LVN A on 08/22/25 at 4:20 pm, LVN A confirmed that she was not aware that patient #3 was on this medication and was only made aware during the visit on 08/21/25. LVN A further confirms that she was responsible for conducting a medication reconciliation at every home visit and the RN was responsible for the plan of care and recertifications for patient #3. LVN A does not know why the medication was not listed on the POC as she only updated medication profiles, skilled nursing notes, communications, and orders. Surveyor asked how an inaccurate plan of care without a current medication and treatments can affect patient care. LVN A confirmed the medication list would be inaccurate, and in her absence, another nurse would not know which medications the patient is receiving or be aware of any potential adverse reactions. In a subsequent interview with LVN A on 08/26/25 at 11:11 am, LVN A confirmed that she spoke with MD A’s medical assistant and in which they stated the medication Citrucel 500mg 3 tablets by mouth every day was ordered by MD A on 06/03/25 for patient #3. Record review of the Agency’s policy manual contained a policy titled, “Plan of Care TX.6”, with a revision date of 12/29/22, quoted in part, “Purpose: To develop an individualized Plan of Care which specifies the care and services necessary to meet the patient specific need and according to state and federal regulations…Policy…The POC will contain the following elements…all medications and treatments…””