Every finding on record at Amedisys Sc, LLC

An onsite unannounced Emergency Preparedness Survey was conducted at Amedisys Camden Home Health from 06/26/2023 to 06/29/2023. Amedisys Camden Home Health is in compliance with the Medicare Conditions at 42 CFR 484.102 (Establishment of the Emergency Program).

An onsite unannounced Recertification Survey and a COVID-19 Staff Vaccination Survey were conducted at Amedisys Camden Home Health from 06/26/2023 to 06/29/2023. Amedisys Camden Home Health is in compliance with the Medicare COVID-19 Staff Vaccine requirements with 77 staff members fully vaccinated, 16 approved religious exemptions,1 approved medical exemption and policy and procedure in place. The home health agency is in substantial compliance with the Medicare Conditions at 42 CFR PART 484 with standard level deficiencies.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record reviews and interview, the home health agency (hha) failed to admit two of 9 patients (Patient #6 and Patient #9) within 48 hours of the physician referral and failed to notify the physician of the delay in patient's Start of Care (SOC). The findings include: On 06/28/2023 at 1:32 PM, review of Patient #6's record revealed the physician referral date was 06/06/2023. Documentation of an attempt to contact the patient on 06/07/2023 and the SOC on 06/11/2023. There was no documentation for the reason for the delay of the patient's SOC or notification to physician. On 06/28/2023 at 2:09 PM, Registered Nurse (RN) #1 reported “We had trouble getting hold of him” and verified the finding. On 06/28/2023 at 8:51 AM, review of Patient #9's record revealed the physician's referral date 01/23/2023 with the patient's SOC dated 02/04/2023. There was no documentation for the reason for the delay or notification to the physician. On 06/29/2023 at 9:08 AM, RN #5 reported “Can’t find any documentation" and verified the finding.

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 observations and record reviews, the home health agency (hha) failed to update the patient's medication profile for 3 of 7 applicable patients. (Patient #5, #6 and #7) The finding includes: During a home visit with Patient #5 on 06/27/2023 between 8:35 AM and 9:20 AM revealed home health agency's medication profile was not accurate in that Humalog Insulin 100 units/ml (milliliters)by subcutaneous injection 30 units 3 times a day listed on the home health agency's medication profile differed from the patient's reported 22 units before breakfast; 30 units before lunch, and 30 units before dinner. Home Health Agency medication profile showed Lasix 20 milligrams (mgs) 1 tablet 3 times a week differed from the patient's reported Lasix 20 mgs i tablet every day. Home Health Agency's medication profile showed Prednisone 5 milligrams 1 tablet daily differed from the patient's reported Prednisone 5 milligrams as needed for wheezing. During a home visit with Patient #6 on 06/27/2023 between 9:35 AM and 10:33 AM revealed home health agency's medication profile was not accurate in that the home health agency's medication profile did not list Rosuvastatin 40 mg 1 tablet by mouth daily but the patient reported taking Rosuvastatin 40 mg 1 tablet by mouth daily. The home health agency medication profile showed Calcium Acetate 667 milligrams 1 capsule 3 times a day but patient reported taking 2 capsules by mouth 3 times a day. The home health agency medication profile showed Humalog Insulin 100 units/ml by subcutaneous injection 6 units 3 times a day but the patient reported Humalog Insulin 100 units/ml by subcutaneous injection 12 units 3 times a day. The home health agency medication profile showed Lantus Insulin 100 units/ml by subcutaneous injection but the patient reported Lantus Insulin 100 units/ml by subcutaneous injection 50 units at bedtime. The home health agency medication profile showed Torsemide 100 mg tablet 1 tablet by mouth twice a day but patient reported Torsemide 100 mg tablet was discontinued. On 06/28/2023 at 2 PM, RN #1 verified the findings. During a home visit with Patient #7 on 06/27/2023 between 10:50 AM and 11:31 AM revealed home health agency's medication profile was not accurate in that the Home Health Agency's medication profile for the patient showed Carvedilol 12.5 mg 1 tablet twice a day but the patient reported taking Carvedilol 3.125 mg 1 tablet by mouth twice a day. Home Health Agency's medication profile showed Tadalafil 20 mg 1 tablet by mouth once ad day but patient reported taking Tadalafil 20 mg 1 tablet by mouth twice a day. The Home Health Agency medication profile showed Torsemide 100 milligram tablet twice a day but the patient reported taking Torsemide 20 mg 1 tablet by mouth daily. The home health agency's medication profile for the patient showed Warfarin 3 mg 1 tablet by mouth daily but patient reported taking Warfarin 5 milligrams tablet by mouth once a day on Mondays and Fridays, 2.5 milligrams tablet on other days. The home health agency medication profile did not have Rosuvastatin 5 mg 1 tablet by mouth daily but the patient reported taking Rosuvastatin 5 mg 1 tablet by mouth daily. The home health agency's medication profile showed Amiodarone 200 mg tablet 1 tablet but the patient reported taking Amiodarone 200 mg tablet 1 tablet by mouth daily. On 06/28/2023 at 2 :09 PM, RN #1 verified the findings.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based upon record review and interview the facility failed to ensure the patients(s) care conform to the physician(s) orders for 3/17 records reviewed which included missed visits by the staff. (#11, #15, #17) The findings are: Chart review on 6/28/23 at 10 AM has Patient #15 with a Start of Care of 4/5/23 and a diagnosis of Pressure Ulcer Stage 3 and a Right Hip Fracture. The physician order includes a Medical Social Worker (MSW) to evaluate for long term care needs. This order fails to appear on the frequency/duration and the MSW puts in a missed visit note in week 1, rescheduling the visit into week 2. The MSW never makes the visit during the entire episode. Physician orders for the Registered Nurse (RN), effective 4/9/23, include one (1) visit for two (2) weeks, then twice a week for six (6) weeks. The medical record reveals the RN made one (1) extra visit in week 3 without an order to do so, but one (1) less visit than ordered in week 4, with no missed visit note. This information was confirmed with the RN Manager #1 on 6/28/23 at 2PM. Chart review on 6/28/23 at 11 AM has Patient #17 with a Start of Care of 5/19/23 with a diagnosis of Chronic Kidney Disease Stage IV, Diabetes type 2, and Chronic Venous Ulcers of the Lower Extremities. Occupational Therapy (OT) was ordered on 5/19/23 to see the patient once every other week, for 2 visits total. The OT does not visit the patient in the interim, but issues a missed visit note on 6/26/23, six weeks later. It was reported by the RN Manager #1 on 6/28/23 during the survey the OT visited the patient that day, but the report was not available for viewing. Facility policy TX-001 (1/3/23) reads: "Drugs, services and treatments are administered only as ordered by a physician or allowed practitioner that establishes and periodically reviews the plan of care." Patient #11 On 06/28/2023 at 11 AM, chart review reveals Occupational Therapist (OT) orders for visit schedule 1 visit a week for 9 weeks starting 03/29/2023. Physician orders dated 05/05/2023 order OT visits 1 visit for 3 weeks starting 05/07/2023. There are 2 OT visits documented for the week starting 05/07/2023. Interview on 06/29/2023 at 9 AM, RN #5 reports “were looking at missed visit the week before” and verifies the finding.

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted in conjunction with a COVID-19 focused infection control survey and the HHA's Recertification Survey from April 12, 2021 to April 15, 2021. Based on observations, record reviews, interviews, review of the HHA's Emergency Preparedness Program, review of the HHA's infection control policies and procedures, it was determined the HHA had standard level deficiencies from its EPP survey and the Recertification survey.

Names and Contact Information CFR(s): 484.102(c)(1) [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).] The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients' physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO's Donation Service Area (DSA). This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's(HHA) Emergency Preparedness Program (EPP) and interview, the HHA failed to include contact information for the staff for use during an emergency. The findings are: On 4/15/21 at 2:00 PM, review of the HHA's EPP revealed the HHA failed to include contact information for the HHA's staff members responsible for the provision of patient services. The findings were verified by the Director of Operations(DOO) on 4/15/21 at 3:00 PM. HHA policy and procedure, titled, " Mitigation Phase Communication Policy", reads, " ....Each office will keep and maintain a current list of contact information for staff, patients, physicians, volunteers, entities providing services under arrangement, vendors, (Federal, State, Tribal, regional and local) emergency services, other appropriate community resources, and other home health and hospice providers ....".

EP Training Program CFR(s): 484.102(d)(1) *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's(HHA) Emergency Preparedness Program(EPP), review of the HHA's personnel files, and interview, the HHA had no documentation of training of 3 of 7 staff on the HHA's EPP. The findings are: On 4/15/21 at 2:00 PM, review of the HHA's EPP revealed the HHA had no documentation that the HHA trained 3 staff on the HHA's Emergency Preparedness Program. The findings were verified by the Director of Operations on 4/15/21 at 3:00 PM. HHA policy and procedure, titled, "Emergency Management Planning", reads, " ....All employees will be oriented to the Emergency Management Plan, including their responsibilities in carrying out the plan upon hire, and annually ....".

EP Testing Requirements CFR(s): 484.102(d)(2) *[For RNCHI at §403.748, ASCs at §416.54, HHAs at §484.102, CORFs at §485.68, OPO, "Organizations" under §485.727, CMHC at §485.920, RHC/FQHC at §491.12, 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 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 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. This STANDARD is not met as evidenced by: Based on review of the Home Health Agency's(HHA)Emergency Preparedness Program (EPP) and interview, the HHA had no documentation that the HHA participated in a community- based or individual facility-based full scale exercise and failed to analyze the HHA's response. The HHA had no documentation of all drills and/or review/update of the HHA's EPP as needed. The findings are: On 4/15/21 at 2:00 PM, review of the HHA's EPP revealed the EPP had no documentation of participation in drills or exercises. The finding was verified by the Director of Operations on 4/15/21 at 3:00 PM, who stated, "We had a drill, but it's not documented." HHA policy and procedure, titled, "Emergency Management Planning", reads, " ....The agency will participate in practice drills, both internal and external to evaluate agency/staff knowledge of role(s) in plan implementation and to assess plan effectiveness ....".

A survey of the Home Health Agency's (HHA) Emergency Preparedness Program (EPP) was conducted in conjunction with a COVID-19 focused infection control survey and the HHA's Recertification Survey from April 12, 2021 to April 15, 2021. Based on observations, record reviews, interviews, review of the HHA's Emergency Preparedness Program, review of the HHA's infection control policies and procedures, it was determined the HHA had standard level deficiencies from its EPP survey and the Recertification survey.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on record reviews, interview, and review of the Home Health Agency's policies and procedures, the Home Health Agency Skilled Nurse (SN) failed to document an assessment of the patient's wound for measurement for two of two patients reviewed for care and services for wounds. (Patient #1 and #2) The findings are: Patient #1 On 4/15/2021 at 2:10 PM, review of Patient #1's chart revealed the SN was ordered to visit the patient once a week. Review of the documentation of the SN's visit dated 3/24/2021 revealed the SN did not document the measurements for the wound on the patient's left iliac crest staged as Stage II. Review of the documentation of the SN's assessment of the patient's wound revealed "No measurements taken". The finding was verified by the Director of Operations (DOO) on 4/15/2021 at 12:53 PM who stated the Home Health Agency's policy for wound assessment states "Wounds are to be measured weekly." Patient #2 On 4/15/2021 at 8:40 AM, review of Patient #2's chart revealed the SN was ordered to visit the patient 2 times a week for five weeks, and then, one time a week beginning on 1/25/2021. The patient's diagnosis was documented as Type 2 Diabetes Mellitus with Foot Ulcer. Review of the SN's documentation of the patient's wound revealed a wound on the patient's right distal dorsum and a wound on the patient's right third toe. Review of the The SN's documentation for both wounds dated 2/17/2021 showed "No measurements taken". Review of the SN's documentation dated 3/24/2021 revealed the SN documented "No measurements taken" for both wounds. The findings were verified by the DOO on 1:01 PM on 4/15/2021. Home Health Agency's policy, titled, "The Provision of Wound and Skin Care", reads, "Policy: Subject: The Provision of Wound and Skin Care". Purpose: To provide general guidance on wound and skin care; to provide additional information on resources used to treat wounds; to provide standardization around the practice of wound and skin care ....Measuring: In accordance with best practice and standard of care, wounds will be measured a minimum of one time a week, preferably on the first visit of the week, by the same nurse, utilizing the same tool and measurement terminology. The preferred day for measuring is the first visit of each week. Patients who are seen at a frequency of one time a week should have the wound measured at that visit. Patient who are seen less frequently than one time a week where the caregivers are responsible for the provision of one care (for example: Foley catheter changes, B12 injections) should have the wound measured when the visit is made ....".