Every finding on record at Always Independent Inc.

Based on the findings of an unannounced onsite Medicare recertification survey conducted January 5, 2023, and concluded offsite on January 6, 2023, Always Independent Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484.22, Subpart B, Conditions of Participation: Home Health Agencies - Emergency Preparedness.

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on interview with the administrator/director of nursing, review of agency documentation and the agency's emergency preparedness plan, the agency failed to base the emergency preparedness plan on and to include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings: A review of the agency emergency preparedness plan was conducted on January 5, 2023, at approximately 11:00 A.M. There was no documentation that the emergency preparedness plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. Interview with the administrator/director of nursing on January 5, 2023, at approximately 1:00 P.M. confirmed the above findings.

EP Testing Requirements CFR(s): 484.102(d)(2) §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed. This STANDARD is not met as evidenced by: Based on review of agency Emergency Preparedness documentation and interview with the Administrator/Director of Nursing, the agency failed to conduct an exercise to test the emergency plan at least annually. Findings Include: A review of agency Emergency Preparedness plan on 1/5/23, at approximately 10:15 A.M. revealed no documentation of exercises to test the emergency plan since one was conducted on 2/24/20. An interview with agency Administrator/Director of Nursing was conducted on 1/5/23, at approximately 1:00 P.M. The Administrator/Director of Nursing confirmed the above finding.

Based on the findings of an unannounced onsite Medicare recertification survey conducted January 5, 2023, and concluded offsite on January 6, 2023, Always Independent Inc., was found not to be in compliance with the requirements of 42 CFR, Part 484, Subparts B and C, Conditions of Participation: Home Health Agencies.

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR), agencies policies and documents, and an interview with the administrator/director of nursing, the agency failed to obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities for one (1) of one (1) clinical record reviewed: CR#1 Review of the agency policy/documentation took place on 1/5/23 at approximately 12:00 PM and revealed the following: Agency welcome packet contains document that states at the top, "Please check each box as proof of receipt and your understanding of the contents explained." Documents contains: Patient consent to treat, patient rights..." Additional document states at the top, "Consent to treatment release information and statement permit payment for Home health Services and Medical Insurance Benefits Home Health Agency Notice of Privacy Practices" states, "I do hereby consent to treatments by agents, employee or representative of Always Independent, Inc. as offered by my physician and/or as may be dictated by prudent medical practice by illness, injury or condition..." In an interview with the administrator/director of nursing on 1/5/23 at approximately 12:15 PM, they acknowledged that the two documents above were not in CR #1's file as required by the agency. A review of clinical records was conducted on 1/5/23 at approximately 10:15 AM and revealed the following: CR#1 Start of Care: 3/1/22. Discharge from Agency 3/29/22. File did not contain documentation of signed Patient rights and consent to start services with agency. An interview with the administrator/director of nursing was conducted on 1/5/23 at approximately 1:00 PM confirmed the above findings.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based upon clinical record review, agency policy review, and an interview with the Director of Nursing/Administrator, it was determined the agency failed to ensure all patient care orders, including verbal orders were recorded in the plan of care for one (1) out of one (1) clinical record reviewed (CR#1) Findings include: Agency policy titled "Acceptance of Patients, Plan of Care, and Medical Supervision " was reviewed on January 5, 2022 at approximately 11:30 A.M. which stated, " Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the agency...The Plan of Care...covers all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items...The total plan of care is reviewed by the attending physician and Always Independent, Inc...Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care...Drugs and treatments are administered by agency staff only as ordered by a physician..." Clinical records were reviewed on 1/5/22 at approximately 10:00 A.M which revealed the following: CR#1 (Start of Care: 3/1/22) revealed no documentation of a "Home Health Certification and Plan of Care" and therefore did not contain the required pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and other appropriate items. File revealed no documentation of physician orders either on Plan of Care or verbal enabling agency to conduct services. There were skilled nursing visits on the following dates: 3/1/22, 3/8/22, 3/15/22, 3/22/22 and 3/29/22. There was no documentation that the physician was notified about the visits. An interview the Administrator/Director of Nursing on January 5, 2022, at approximately 1:00 PM confirmed the above findings.

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 upon clinical record review, agency policy review, and an interview with the Director of Nursing/Administrator, it was determined the agency failed to ensure Home Health Certification and Plan of Care/Treatment was created and signed by a physician for one (1) out of one (1) clinical record reviewed (CR#1) Findings include: Agency policy titled "Acceptance of Patients, Plan of Care, and Medical Supervision " was reviewed on January 5, 2022 at approximately 11:30 A.M. which stated, " Patients are accepted for treatment on the basis of a reasonable expectation that the patient's medical, nursing and social needs can be met adequately by the agency...The Plan of Care...covers all pertinent diagnosis, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, any safety measures to protect against injury, instructions for timely discharge or referral, and any other appropriate items...The total plan of care is reviewed by the attending physician and Always Independent, Inc...Agency professional staff promptly alert the physician to any changes that suggest a need to alter the plan of care...Drugs and treatments are administered by agency staff only as ordered by a physician..." Clinical records were reviewed on 1/5/22 at approximately 10:00 A.M which revealed the following: CR#1 (Start of Care: 3/1/22) revealed no documentation of a "Home Health Certification and Plan of Care" and therefore did not contain the required pertinent diagnoses, including mental status, types of services and equipment required, frequency of visits, prognosis, rehabilitation potential, functional limitations, activities permitted, nutritional requirements, medications and treatments, safety measures to protect against injury, instructions for timely discharge or referral and other appropriate items. File revealed no documentation of physician orders either on Plan of Care or verbal enabling agency to conduct services. There were skilled nursing visits on the following dates: 3/1/22, 3/8/22, 3/15/22, 3/22/22 and 3/29/22. There was no documentation that the physician was notified about the visits. An interview the Administrator/Director of Nursing on January 5, 2022, at approximately 1:00 PM confirmed the above findings.

Governing body CFR(s): 484.105(a) Standard: Governing body. A governing body (or designated persons so functioning) must assume full legal authority and responsibility for the agency's overall management and operation, the provision of all home health services, fiscal operations, review of the agency's budget and its operational plans, and its quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on a review of agency documentation, policy and procedure and interview with the administrator, it was revealed the agency lacked documentation in their meeting minutes for the fiscal affairs of the agency in regard to approving an annual operating budget and reviewing the annual program evaluation. Findings include: Review of agency policy was conducted on 1/5/23 at approximately 11:20 AM and revealed the following: Policy titled, "Organization, Services and Administration" stated " A Governing Body (or designated person so functioning) assumes full legal authority and responsibility for the operation of the agency. The Governing Body appoints a qualified administrator, arranges for professional advice...adopts and periodically reviews written bylaws or an acceptable equivalent, and oversees the management and fiscal affairs of the agency..." Policy titled, "Budget and Planning" stated, "Always Independent, Inc. under the direction of the Governing Body, prepares an overall plan and a budget includes an annual operating budget and capital expenditure which is reviewed and approved by the Board of Directors." Review of agency documentation on 1/5/23 at approximately 11:25 AM revealed documentation of Governing Body meetings held on 2/14/22, 5/12/22, 8/15/22 and 11/44/22. There was no documentation contained in those meeting minutes about annual budget or approving annual program evaluation. Interview with the Director of Nursing/Administrator on 1/5/23 at approximately 1:00 PM confirmed the above findings.

Ensure that HHA employs qualified personnel CFR(s): 484.105(b)(1)(iv) (iv) Ensure that the HHA employs qualified personnel, including assuring the development of personnel qualifications and policies. This ELEMENT is not met as evidenced by: Based on a review of clinical records (CR), agency policy, and an interview with the administrator/director of nursing, the administrator failed to follow the agency's personnel requirements of annual performance evaluations for one (1) of one (1) personnel file (PF) reviewed (PF#1) Review of agency policy was conducted on 1/5/23 at approximately 12:15 PM and revealed the following: Policy titled, "Annual review" stated, "As an employee of Always Independent, Inc. you will have an annual review interview. The purpose of this interview is to review performance over the past year and to receive feedback from the employee..." A review of personnel files was conducted on 1/5/23 at approximately 9:45 AM and revealed the following: PF#1: Date of Hire: 2/2/13. File did not contain any documentation of annual performance reviews since the date of hire. An interview with the administrator/director of nursing was conducted on 1/5/23 at approximately 1:00 PM confirmed the above findings.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on staff interview, review of agency meeting minutes and staff files it was unable to be determined if the agency appointed an alternate administrator to act in the absence of the administrator. Findings include: An interview with the Administrator/Director of Nursing (DON) was conducted January 5, 2023, at approximately 11:00 A.M. When asked who the alternate administrator/alternate director of nursing was the DON responded there was not an alternate for either the Administrator or Director of Nursing roles. A review of the Professional Advisory Committee/Governing Body meeting minutes that were dated 2/14/22, 5/12/22, 8/15/22, and 11/14/22 contained no mention about needing to fill alternate director of nursing/alternate administrator roles. An interview with the agency administrator/director of nursing was conducted January 5, 2023, at approximately 1:00 PM confirmed the above findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on a review of clinical records (CRs) and an interview with the administrator/director of nursing, agency failed to provide documentation that a discharge summary was sent to the physician within five (5) days of discharge for one (1) of one (1) discharge records reviewed (CR #1). Findings Include: Agency policy about discharge summary was requested on 1/5/23 at approximately 12:00 PM and administrator/director of nursing unable to produce. A review of clinical record conducted on 1/5/23, at approximately 10:30 A.M. which revealed the following: CR#1, start of care (SOC): 3/1/22. Patient was discharged from the agency 3/29/22. There was no documentation that the discharge summary was sent to the physician. An interview with the administrator/director of nursing on 1/5/23 at approximately 1:00 P.M. confirmed the above findings.

Registered Nurse CFR(s): 484.115(k) Standard: Registered nurse. A graduate of an approved school of professional nursing who is licensed in the state where practicing. This STANDARD is not met as evidenced by: Based on clinical record review, review of policy, and an interview with the director of nursing/administrator, the registered Nurse did not follow best practice guidelines concerning wound management for one (1) of one (1) clinical records reviewed (CR# 1) Findings include: The agency's policy concerning wound management was requested on 1/5/23 at approximately 12:30 PM and Director of Nursing/Administrator stated that the agency did not have a policy concerning wound management. A review of the "Organization of Wound Care Nurses & Allied Health professionals" website on 1/5/23 at approximately 2:00PM under "Wound Care review: Best practice guidelines" stated that "weekly measurements of wounds shall be completed and documented in the medical records..." Review of Clinical record occurred on 1/5/23 at approximately 10:30 AM and revealed the following: CR#1 (Start of Care: 3/1/22) On initial nursing assessment documentation from 3/1/22 there was documentation stating, "right great toe with open area on underside cleaned, betadine (antiseptic solution) dressing applied, covered and secured." There was no documentation about initial wound measurements or weekly wound measurements. An interview with the agency's administrator/director of nursing on 1/5/23 at approximately 1:00 pm confirmed the above findings.