Every finding on record at Amedisys Delaware, L.L.C.

A partial extended recertification survey, which ended on 1/23/23, was conducted at Amedisys Home Health, for the purpose of determining the agency's compliance with Medicare requirements. Survey activities included the review of 13 clinical records, 5 home visits, agency document and policy review and interviews with patients and staff. The agency was determined to be out of compliance with the following standards as required by 42 CFR Part 484, Requirements for Home Health Agencies.

A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This ELEMENT is not met as evidenced by: Based on observation, clinical record review, policy review and staff interview, it was determined that the agency failed to ensure a comprehensive medication review was performed for 2 of 13 patients (Patient #’s 9 and 10) in the sample. Findings include: Agency policy titled “Patient Assessment/Reassessment” stated, “…Review all medications the patient is currently using…” Agency policy titled “Drug Regimen Review (Home Health Only)” stated, “…To identify…the patient’s current medication regimen…The clinician completing the OASIS Assessment must complete a comprehensive drug regimen review of all medications the patient is currently taking…The clinician will question the patient and/or caregiver periodically regarding changes in medications…The clinician will also ask the patient to periodically allow them to visualize all the medications the patient is currently taking. (Medications will be visualized minimally at SOC (start of care)…” A. Patient #9 1. During a home visit to Patient #9 on 1/19/23 between 2:30 and 3:20 PM: - Employee #13 asked Patient #9 if there have been any changes to her medications. - Surveyor requested caregiver bring Patient #9’s medications to him/her for review with “Client Medication Report” dated 1/19/23 1:29 PM. - Caregiver provided surveyor with bottle labeled Allopurinol 100mg 1 po (by mouth) daily, which was prescribed 5/2022 and last refilled 11/2022. - Patient #9 states she takes 1 Allopurinol pill once a day. 2. Clinical record review revealed: - “Home Health Certification and Plan of Care” for certification period 12/7/22 to 2/4/23 documents the following medications: a. Amlodipine 10 mg (milligram) tablet daily oral b. Atorvastatin 40 mg tablet daily oral c. Bumetanide 1 mg tablet daily oral d. Diclofenac 1% topical gel 4 times daily/prn (as needed) topical e. Lisinopril 5 mg tablet daily oral f. Multiple Vitamins tablet 1 tablet daily oral g. Tramadol 50 mg tablet every 6 hours if needed/prn oral - “Client Medication Report” dated 1/19/23 1:29 PM documents the following medications were reviewed by Employee #13 on 12/8/22: a. Amlodipine 10 mg (milligram) tablet daily oral b. Atorvastatin 40 mg tablet daily oral c. Bumetanide 1 mg tablet daily oral d. Diclofenac 1% topical gel 4 times daily/prn (as needed) topical e. Lisinopril 5 mg tablet daily oral f. Multiple Vitamins tablet 1 tablet daily oral g. Tramadol 50 mg tablet every 6 hours if needed/prn oral - The clinical record has no evidence that Patient #9 is prescribed Allopurinol 100mg 1 po daily. This finding was confirmed with Employee #13, Physican Therapist, on 1/19/23 at 3:30 PM. B. Patient #10 1. During a home visit to Patient #10 on 1/19/23 between 10:50 and 11:25 AM: - Surveyor requested the current medications Patient #10 is taking to review with “Client Medication Report” dated 1/18/23 2:25 PM. - Patient #10 showed surveyor with a list of medications on his/her tablet via his/her physician’s health portal that included Eliquis 5 mg po BID (twice a day). -- Patient #10 stated she is taking the Eliquis as ordered and that it was ordered for 30 days which ends on Saturday (1/21/23). Prescription started approximately 12/22/22. 2. Clinical record review revealed: - “Home Health Certification and Plan of Care” for certification period 11/22/22 to 1/20/23 documents the following medications: a. Acetaminophen 500 mg tablet every 8 hours/prn oral b. Aspirin Children 81 mg chewable tablet daily oral c. Atorvastatin 10 mg tablet daily oral d. Diclofenac 1% topical gel 2 times daily/prn topical e. Famotidine 40 mg tablet at bedtime oral f. Levothyroxine 75 mcg (micrograms) tablet daily oral g. Linzess 145 mcg capsule 1 daily prn oral h. Nexium 40 mg capsule delayed response daily oral i. Oxycodone 5 mg tablet every 4 hours if needed/prn oral j. Tamsulosin 0.4 mg capsule daily oral - “Client Medication Report” dated 1/18/23 2:25 PM documents the following medications were reviewed by Employee #12 on 12/28/22: Current medications: a. Acetaminophen 500 mg tablet every 8 hours/prn oral b. Aspirin Children 81 mg chewable tablet daily oral c. Atorvastatin 10 mg tablet daily oral d. Diclofenac 1% topical gel 2 times daily/prn topical e. Famotidine 40 mg tablet at bedtime oral f. Levothyroxine 75 mcg (micrograms) tablet daily oral g. Linzess 145 mcg capsule 1 daily prn oral h. Nexium 40 mg capsule delayed response daily oral i. Oxycodone 5 mg tablet every 4 hours if needed/prn oral Discontinued medications: a. Amoxicillin 875 mg-Potassium Clavulanate 125 mg tablet discontinued 12/31/22. a. Tamsulosin 0.4 mg capsule daily oral discontinued 11/22/22. - The clinical record has no evidence that Patient #10 is prescribed Eliquis 5 mg po BID. This finding was confirmed with Employee #1, Director of Operations, on 1/20/23 at 1:55 PM. .

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined that the agency failed to ensure each patient received the home health services that were written in an individualized plan of care and which is established, periodically reviewed, and signed by a doctor for 5 out of 13 patients sampled (patients 7, 8, 9, 10, and 13). Findings include: C. Patient #7 - “Plan of Care Update” dated 11/10/22, included physician orders for PT (physical therapy) effective 11/13/22 2WK5 (2 times a week for 5 weeks). - “Clinical Episode Coordination Notes Report” shows no evidence that 2 PT visits were completed between 12/4/22 to 12/17/22 (weeks #4 and 5 of order effective date). - “Missed Visit Notification” dated 12/9/22 and 12/18/22 documents no evidence the physician was notified of the 12/8/22 and 12/15/22 missed visits or modification of plan of care. - “Plan of Care Update” dated 11/16/22, included physician orders for OT (occupational therapy) effective 11/20/22 1WK4 (1 time a week for 4 weeks). - “Clinical Episode Coordination Notes Report” shows no evidence OT visits were completed between 11/20/22 and 12/3/22 (weeks #1 and 2 of order effective date). - “Missed Visit Notification” dated 11/25/22 and 12/3/22 documents no evidence the physician was notified of the 11/23/22 and 12/2/22 missed visits or modification of plan of care. These findings were confirmed with Employee #1, Director of Operations (DOO), on 1/19/23 between 12:37 PM and 12:50 PM. D. Patient #8 - “Home Health Certification and Plan of Care” for the period of 11/24/22 to 1/22/23, included physician orders for HHA (Home Health Aide) effective 11/27/22 1WK4 (1 time a week for 4 weeks). - “Weekly Verified and Missed Visits Summary” shows no evidence a HHA visit was completed during the week of 11/27/22 (week #1 of order effective date). - “Clinical Episode Coordination Notes Report” shows no evidence a HHA visit was completed between 11/27/22 to 12/3/22 (week #3 of order effective date). - “Missed Visit Notification” dated 12/4/22 documents no evidence the physician was notified of the 12/3/22 missed visit or modification of plan of care. This finding was confirmed with Employee #1, Director of Operations (DOO), on 1/20/23 at 11:01 AM. - “Visits to Orders Comparison Report” for the period of 11/24/22 to 1/22/23, included physician orders for OT (occupational therapy) effective 1/8/23 1WK1 (1 time a week for 1 week). - “Weekly Verified and Missed Visits Summary” shows no evidence a HHA visit was completed during the week of 1/8/23 (week #1 of order effective date). - “Clinical Episode Coordination Notes Report” shows no evidence a HHA visit was completed between 1/8/23 to 1/14/23 (week #1 of order effective date). - “Missed Visit Notification” dated 1/13/23 documents no evidence the physician was notified of the 1/12/23 missed visit or modification of plan of care. This finding was confirmed with Employee #1, Director of Operations (DOO), on 1/20/23 at 11:10 AM. E. Patient #13 - “Visits to Orders Comparison Report” for the period of 10/22/22 to 12/20/22, included physician orders for HHA (home health aid visits) effective 11/20/22 1WK4 (1 time a week for 4 weeks). - “Weekly Verified and Missed Visits Summary” shows no evidence a HHA visit was completed during the week of 11/27/22 (week #2 of order effective date). - “Clinical Episode Coordination Notes Report” shows no evidence a HHA visit was completed between 11/27/22 to 12/3/22 (week #2 of order effective date). - “Missed Visit Notification” dated 11/29/22 documents no evidence the physician was notified of the 11/27/22 missed visit or modification of plan of care. This finding was confirmed with Employee #1, Director of Operations (DOO), on 1/23/23 at 1:00 PM. Agency policy titled “Physician Orders and Medical Supervision of the Plan of Care” stated, “…Each patient receives the home health services that are written in an individualized plan of care…” Agency policy titled “Documenting a Missed Visit” states, “…require a notification of the missed visit…The clinician must contact the physician or a physician representative to notify them of the missed visit…” A. Patient #9 - “Home Health Certification and Plan of Care” for the period of 12/7/22 to 2/4/23, included physician orders for HHA (Home Health Aide) effective 12/11/22 1WK4 (1 time a week for 4 weeks). - “Weekly Verified and Missed Visits Summary” shows no evidence a HHA visit was completed during the week of 12/25/22 (week #3 of order effective date). - “Clinical Episode Coordination Notes Report” shows no evidence a HHA visit was completed between 12/25/22 to 12/31/22 (week #3 of order effective date). - “Missed Visit Notification” dated 12/23/22 documents no evidence the physician was notified of the 12/22/22 missed visit or modification of plan of care. This finding was confirmed with Employee #1, Director of Operations (DOO), on 1/23/23 at 1:21 PM. B. Patient #10 - “Home Health Certification and Plan of Care” for the period of 11/22/22 to 1/20/23, included physician orders for HHA (Home Health Aide) effective 11/27/22 2WK2 (2 times a week for 2 weeks). - “Weekly Verified and Missed Visits Summary” shows no evidence that 2 HHA visits were completed during the week of 11/27/22 (week #1 of order effective date). - “Clinical Episode Coordination Notes Report” shows no evidence that 2 HHA visit were completed between 11/27/22 to 12/3/22 (week #1 of order effective date). - “Missed Visit Notification” dated 12/4/22 documents no evidence the physician was notified of the 12/3/22 missed visit or modification of plan of care.

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined that for 4 of 13 patients (Patient #’s 4, 8, 11, and 12) in the sample, the agency failed to ensure verbal orders were authenticated and dated by the physician in accordance with their internal policy. Findings include: B. Patient #8 Review of clinical record revealed: - Physician order for Home Health Certification and Plan of Care dated 11/24/22 - Order authenticated and dated by the physician on 1/18/23 (55 days after order given). Employee #1, Director of Operations (DOO), confirmed this finding during an interview on 1/20/23 at 10:52 AM. C. Patient #11 Review of clinical record revealed: - Physician order for Home Health Certification and Plan of Care dated 12/6/22 - Order authenticated and dated by the physician on 1/12/23 (37 days after order given). Employee #1, Director of Operations (DOO), confirmed this finding during an interview on 1/23/23 at 1:09 PM. D. Patient #12 Review of clinical record revealed: -Home Health Certification and Plan of Care for the certification period of 12/19/22 to 2/16/23 shows a date of 12/19/22 for when the verbal order was received. -As of 1/23/23 there was no evidence of the order being signed by the ordering provider (35 days after the date of receipt). Employee #1, Director of Operations (DOO), confirmed this finding during an interview on 1/23/23 at 1:08 PM. Agency policy titled “Physician Verbal Orders” stated, “…The order must be signed and returned to the office…no longer than 30 days…” Agency policy titled “Physician Orders and Medical Supervision of the Plan of Care” states, “The agency requires submission and return of physician orders…not longer than 30 days…” A. Patient #4 Review clinical record revealed: - Physician verbal order dated 2/1/22 for “…patient to be on hold for 2 weeks as per oncologist…” - Order authenticated and dated by physician on 4/14/22 (72 days after order given). - No evidence the 2/1/22 verbal order was authenticated and dated by the physician until 72 days after order given. Employee #1, Director of Operations (DOO), confirmed this finding during an interview on 1/23/23 between 1:20 to 1:30 PM.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policies, and staff interview, it was determined that for 2 of 13 patients (Patient #'s 1 and 12) sampled, the agency failed to promptly alert the relevant physician to changes in the patient's condition that suggested the plan of care should be altered. . B. Patient #12 clinical record review: -“Visits to Orders Comparison Report” for the certification period from 12/19/2022 to 2/16/2023 showed orders for PT (physical therapy) 1WK1, 2WK4, 1WK4 (once a week for one week, twice a week for four weeks, and once a week for four weeks) starting 12/19/2022 -“Visit Note Report” dated 1/19/23 (week 5 of ordered therapy) has “DC of PT Services” [discharge of physical therapy services] as the visit type. The note also states “On visit PT [patient] shows meeting his goal…PT is ok with DC and understands reason of it. PT also adds that he is ready to DC…” -No evidence of provider notification of the patient’s change in condition resulting in a change to the care plan. -No evidence of orders to discontinue physical therapy services. Employee #1, DOO (Director of Operations), confirmed these findings in an interview on 1/23/23 at 1:08 PM. Agency policy titled "Patient Assessment/Reassessment" stated, "...The patient's primary physician...will be notified of changes/updates in the patient's condition...Any changes in the patient's condition or needs indicating outcomes are not being achieved and/or that the plan of care should be altered..." A. Patient #1 clinical record review: - "Client Episode Coordination Notes Report" dated 9/7/22 (Wednesday) documents Employee #18 completed a physical therapy visit and reported, "Patient's status is deteriorating...now requires MODA (moderate assistance) for transfers and mobility...will be seeing doctor on Monday…" - Patient #1 discharged from services on 9/21/22 to Hospice services. - No evidence in clinical record that physician was notified of Patient #1’s change of condition between 9/7/22 and discharge on 9/21/22. Employee #1, DOO (Director of Operations), confirmed this finding during an interview on 1/19/23 at 2:39 PM.

Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This STANDARD is not met as evidenced by: Based on observation, clinical record review, policy review, and staff interview, it was determined that for 1 of 2 patients (Patient # 7) observed during skilled nursing (SN) home visits, the agency staff failed to adhere to accepted standards of practice regarding hand hygiene. Findings included: Agency policy titled “Hand Hygiene” states “…Perform hand hygiene as follows: Before having direct contact with patients; before donning gloves;… After contact with a patient’s intact skin;…after removing gloves…” A. Patient 7 On 1/19/23 during a home visit between 10:00 AM and 10:38 AM the following was observed as a registered nurse provided care to the patient: -donned gloves -took vital signs -doffed gloves -hand hygiene was performed using hand sanitizer -donned gloves -incontinence care was provided -doffed gloves -gathered supplies to finish incontinence care -donned gloves Hand hygiene was not performed per policy -prior to donning gloves to take vital signs -after doffing gloves in order to gather supplies -prior to donning gloves to complete incontinence care These findings were confirmed by Employee #7, RN on 1/19/23 at 10:35 AM.

Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated in the plan of care; This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined that for 4 of 13 (Patient #’s 1, 4, 8, and 13) patients sampled with skilled services, the agency failed to provide services as ordered by the physician in the plan of care. Findings include: C. Patient #8 Review of clinical record revealed: - Visits to Orders Comparison Report for the period of 11/24/22 to 1/22/23 included orders for PT (Physical Therapy) 2EVERY2WK2 (two times a week every 2 weeks) effective 11/27/22. -No evidence of physical therapy visits for the week of 11/27/22. Employee #1, DOO (Director of Operations), confirmed that there were 2 missed Physical Therapy visits for the week of 11/27/22 during an interview on 1/20/23 between 10:52 AM and 11:10 AM. D. Patient #13 Review of clinical record revealed: - Visits to Orders Comparison Report for the period of 10/22/22 to 12/20/22 included orders for OT (Occupational Therapy) 1WK3, 1EVERY2WK2, 1WK1 (once a week for 3 weeks, once every 2 weeks for 2 weeks, and once a week for one week) effective 10/30/22. -No evidence of occupational therapy visits for the week of 11/27/22. Employee #1, DOO (Director of Operations), confirmed that there was 1 missed occupational therapy visit for the week of 11/27/22 during an interview on 1/23/23 at 1:03 PM. Agency policy titled “Physician Orders and Medical Supervision of the Plan of Care”, stated, “…The agency provides care and services according to the most recent physician order…” A. Patient #1 clinical record review revealed: 1. “Home Health Certification and Plan of Care” for the period of 7/29/22 to 9/26/22, included physician orders for HHA (Home Health Aides) effective 7/31/22 2WK1, 1WK2 (2 times a week for 1 week and 1 time a week for 2 weeks) - “Weekly Verified and Missed Visits Summary” shows no evidence a HHA visit was completed during the week of 8/14/22 (week #3 of order effective date to patient discharge from services 9/21/22). - “Clinical Episode Coordination Notes Report” shows no evidence a HHA visit was completed between 8/14/22 and 9/21/22 (week #3 of order effective date to patient discharge from services 9/21/22). Employee #1, DOO (Director of Operations), confirmed this finding during an interview on 1/20/23 at 2:30 PM. 2. “Home Health Certification and Plan of Care” for the period of 7/29/22 to 9/26/22, included physician orders for PT (Physical Therapy) effective 7/31/22 1WK1, 2WK2, 1WK4(1 time a week for 1 week, 2 times a week for 2 weeks, 1 time a week for 4 weeks). - “Weekly Verified and Missed Visits Summary” shows no evidence a PT visit was completed during the week of 9/11/22 (week #7 of order effective date). - “Clinical Episode Coordination Notes Report” shows no evidence a PT visit was completed during the week of 9/11/22 (week #7 of order effective date). Employee #1, DOO (Director of Operations), confirmed this finding during an interview on 1/20/23 at 2:30 PM. B. Patient #4 clinical record review revealed: - “Home Health Certification and Plan of Care” for the period of 12/21/21 to 2/18/22, included physician orders for PT (Physical Therapy) 2WK4, 1WK5 (2 times a week for 4 weeks, 1 time a week for 5 weeks). - “Weekly Verified and Missed Visits Summary” shows no evidence a PT visit was completed during the week of 1/23/22 (week #6 of order date). - “Clinical Episode Coordination Notes Report” shows no evidence a PT visit was completed during the week of 1/23/22 (week #6 of order date). Employee #1, DOO (Director of Operations), confirmed this finding during an interview on 1/23/23 at between 1:20 to 1:30 PM.

Nursing services supervised by RN CFR(s): 484.75(c)(1) Nursing services are provided under the supervision of a registered nurse that meets the requirements of §484.115(k). This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined that for 1 of 9 patients (Patient #5) in the sample who received skilled nursing services, the agency failed to ensure nursing services were supervised by a registered nurse per agency policy. Findings include: Agency policy titled “Supervision of Disciplines – RN/LPN [registered nurse/licensed practical nurse]” states “…The Registered Nurse must supervise the LPN/LVN [licensed vocational nurse] every 30 days…” A. Patient #5 Review of clinical record revealed: -During the review period from 11/20/22 to 1/20/23 there were orders for the patient to receive skilled nursing visits at a frequency of 1WK1, 3WK8 (once a week for one week and 3 times a week for 8 weeks) effective 10/28/22 and 2 WK1, 3WK8 (twice a week for one week and three times a week for 8 weeks) effective 12/27/22. -Skilled nursing visits were completed by LPN’s at least weekly during the review period. -No evidence of LPN supervisory visits conducted by an RN during this review period. Employee #1, DOO (Director of Operations), confirmed this finding during an interview on 1/20/23 at 2:55 PM.

Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This ELEMENT is not met as evidenced by: Based on clinical record review, policy review and staff interview, it was determined that the agency failed to ensure a HHA supervisory visit was completed by a registered nurse of other appropriate skilled professional every 14 days for 1 of 3 patients (Patient #10) in the sample receiving HHA services. Findings include: Agency Policy titled "Services Provided/Supervision of Disciplines - HHA" stated, "...A supervisory visit will be made to the patient's residence at least every 14 days or less, by the RN (registered nurse)...The home health aide does not have to be present. In cases where both skilled nursing and therapy services are involved, the skilled nurse makes the supervisory visit..." Patient #10 clinical record review revealed: "Home Health Updated Plan of Care Report" for certification period 11/22/22 to 1/20/23 documents resumption of care orders dated 12/21/22 for SN (skilled nursing) 1wk3, 1everyothee2wk2 (1 times a week for 3 weeks, 1 every other 2 weeks for 2 weeks) and HHA (home health aide) effective 12/25/22 1wk4 (1 times a week for 4 weeks). "Visits to Orders Comparison Report" documents: - HHA visits made on 12/28/22 (week of 12/25/22), 1/4/23 (week of 1/1/23), 1/11/23 (week of 1/8/23), and 1/16/22 (week of 1/15/23) - No evidence that a skilled nurse made a HHA supervisory visit to the patient's residence between 12/28/22 through 1/20/23 (23 days). This finding was confirmed with Employee #1, Director of Operations, on 1/20/23 at 1:51 PM. .

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on clinical record review, policy review, and staff interview, it was determined that for 3 of 13 (Patient #’s 5, 7, and 8) patients sampled clinical notes were incomplete per facility policy. Findings include: Agency policy titled "Guide for Documenting a Missed Visit" states "...The care center clinicians will make ALL efforts to avoid a missed visit by rescheduling or reassigning a visit to comply with the ordered frequency. A visit is not to be considered missed until the Medicare week is completed and the visit was not made in accordance with the physician order. Coordination of care standards require a notification to the physician and documentation of the missed visit in a timely manner..." Agency policy titled "Section 7 - Scheduling" states "...The proper completion of the Missed Visit Notification Coordination Note will include: Visit date, Discipline, Reason for missed visit, Why visit cannot be rescheduled..." A. Patient #5 Review of clinical record revealed: -Missed visit note dated 1/11/23 failed to include documentation of a reason the visit was unable to be rescheduled. Employee #1, DOO (Director of Operations), confirmed this finding during an interview on 1/20/23 at 2:53 PM. B. Patient #7 Review of clinical record revealed: -Missed visit note dated 1/7/23 failed to include documentation of a reason the visit was unable to be rescheduled. Employee #1, DOO (Director of Operations), confirmed this finding during an interview on 1/19/23 between 12:37 PM and 12:50 PM. C. Patient #8 Review of clinical record revealed: -Missed visit notes dated 1/1/23 and 1/9/23 failed to include documentation of a reason the visit was unable to be rescheduled. Employee #1, DOO (Director of Operations), confirmed these findings during an interview on 1/20/23 between 10:52 AM and 11:10 AM.