Every finding on record at Angel Bright Home Health Inc

Purpose of Visit: To conduct RE-Certification, a Follow-up to survey dated 02/05/20, and 8 Complaints and 2 Self-Reported Incidents. On 12/28/22 at 10:55 a.m., Surveyor AA conducted an unannounced visit, and an entrance conference was conducted with the Adm and DON. Census: Licensed & Certified- 173 Licensed Home Health Services - 0 Personal Assistance Services – 676 Parent & 5 Branch= 681 An exit conference was conducted on 01/06/23 at 12:35 p.m., with the Adm, Alt Adm, DON, PHC office Manager, and Administrative Assistant/Billing Supervisor. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Deficiencies. The agency was in compliance with 42 CFR Part 484.102, Emergency Preparedness Requirements for Home Health Agencies

Purpose of Visit: To conduct Re-Certification, a Follow-up to survey dated 02/05/20, and 8 Complaints and 2 Self-Reported Incidents. On 12/28/22 at 10:55 a.m., Surveyor conducted an unannounced visit, and an entrance conference was conducted with the Adm and DON. Census: Licensed & Certified- 173 Licensed Home Health Services - 0 Personal Assistance Services – 676 Parent & 5 Branch= 681 An exit conference was conducted on 01/06/23 at 12:35 p.m., with the Adm, Alt Adm, DON, PHC office Manager, and Administrative Assistant/Billing Supervisor. The preliminary findings were discussed. The agency was given the opportunity to provide additional information. Written instructions were provided for submitting a Plan of Correction within 10 days of receipt of the Statement of Deficiencies. Ac-before meals Adm- Administrator ADON-Alternate Director of Nurses Alt- Alternate AM-ante meridiem BID- Twice a day Cap-Capsule DON- Director of Nurses DR- Doctor hrs-hours hs-hour of sleep Inh- inhalation iu-international units LVN- Licensed Vocational Nurse Mcg-micrograms Mg- Milligrams ml- milliliters NS-Normal Saline NSTEMI- Non-St-Elevation Myocardial infarction (a lesser severe heart attack that causes less damage to the heart) OASIS- Outcome and Assessment Information Set OT- occupational therapy Oz-ounces PHC- Primary Home Care Pm- post meridiem po- by mouth POC- Plan of Care PRN- as needed PT-physical therapy q- every qd- every day qhs-ever hour of sleep QID- Four times a day RN- Registered Nurse SBP- systolic blood pressure SN- Skilled Nurse Sq- subcutaneous tab- tablet TID- three times a day

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, observation, and interview, the agency failed to ensure the patient’s medication lists were updated to assure that all the drugs were indicated and to identify ineffective drug therapy, drug side effects, actual or potential drug interactions, and duplicate drug therapy for 2 of 9 active patients (#2 and #10) whose records were reviewed. This failure could place the agency's patients at risk for potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions and duplicate drug therapy. The findings included: 1. A review of Patient #2’s medications during a Home Visit conducted on 01/05/23 between 9:00 a.m. and 10:15 a.m., revealed medication bottles which were reviewed with Patient #2 and LVN as follows: -Norvasc (for high blood pressure) 5mg 1-tab po q day “I [patient#2] have been taking it for about a week, I failed to tell the nurse” Effective date on medication bottle read 11/07/22. -Omeprazole (helps treat heartburn) 40 mg 1 cap po q day “it’s been about a month” Effective date on medication bottle read 11/23/22. -Atorvastatin (helps lower cholesterol) 80 mg tablet 1-tab po q day. Effective date on medication bottle read 08/09/22. -Trazodone (for depression) 150 mg 1-tab po q hs. Effective date on medication bottle read 12/21/22. -Metoprolol (for high blood pressure) 50 mg 1-tab po BID “I stopped it about a month ago.” -Promethazine (for nausea) 25 mg 1-tab po q 6hrs as needed. Effective date on medication bottle read 12/19/22. -Duloxetine (for depression and anxiety) 60 mg 1 cap po q hs. Effective date on medication bottle read 06/16/22. -Vitamin C (helps immune system) 500 mg 1-tab po q day “I have been taking it since May 2022.” -Zinc (helps support immune system)50 mg 1-tab po q day “I have been taking it since May 2022.” -Vitamin A(important nutrient to vision, growth and immunity) 2500 mcg 1-tab po q day “I have been taking it since May 2022.” -Vitamin D3 (helps body absorb calcium)125mcg (5000 iu)1 tab q day “I have been taking it since May 2022.” -Aleve (for pain) 220 mg 2 tabs q am and 2 tabs q pm “I have been taking it for a while.” -Trulicity/Tresiba Flextouch (for diabetes) 100 units/ ml 12 units qhs “I have been using it for 4 or 5 years.” -Albuterol (for treatment or prevention wheezing and shortness of breath) 2 puffs daily prn INH - Aspirin (thins the blood) 81 mg 1-tab qd po -Clopidogrel (helps blood from sticking together) 75 mg 1-tab po -Dulaglutide (for diabetes) 1.5 mg Qweekly[sic] sq -Levothyroxine (for thyroid) 112mcg 1-tab qd po -Lisinopril (for high blood pressure) 20 mg 1-tab qd po -Metoclopramide (for stomach)10 mg 1-tab QID po -Normal Saline (to clean wound(s))100 ml Three times a week topical -Novolog (for diabetes)100 units/ml Mild sliding scale AC & HS; 151-200=2 units; 201-250=4 units; 251-300= 6 units;301-350= 8 units; 351-400= 10 units As per patient #2 the following have been discontinued: -Gabapentin (for pain)300 mg 1-tab TID PO “it was discontinued 2 months ago.” -Hydrocodone/Acetaminophen (for pain) 7.5/32mg 1 tab q 6hrs prn po “it was discontinued in May 2022.” -Lactobacillus 2 (to help treat or prevent diarrhea) tab[sic] qd po “it was discontinued back on 11/23/22” -Santyl (for wounds) 4 oz. three times a week topical “that was discontinued about 1 year ago.” -Tylenol (for pain) #4 1-tab TID PRN po “it was discontinued, it’s been a while.” Review of Patient #2's clinical record included a POC signed and dated by RN F on 11/14/22 for the Certification period of 11/17/22 to 01/15/23 with a primary diagnosis of Type 2 diabetes (Diabetes Mellitus is condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels) with diabetic peripheral angiopathy (a disease caused by high blood sugars affecting the blood vessels) with gangrene (a condition that occurs when tissue dies turning the body part black or purplish due to decrease circulation). The POC included a SN visit frequency of once a day for sixty days. Further review of the POC for the Certification period of 11/17/22 to 01/15/23 revealed no documented evidence that it included the following medications observed in the home: -Norvasc (for high blood pressure) 5mg 1-tab po q day “I [patient#2] have been taking it for about a week, I failed to tell the nurse” Effective date on medication bottle read 11/07/22. -Omeprazole (helps treat heartburn) 40 mg 1 cap po q day “it’s been about a month” Effective date on medication bottle read 11/23/22. -Atorvastatin (helps lower cholesterol) 80 mg tablet 1-tab po q day. Effective date on medication bottle read 08/09/22. -Trazodone (for depression) 150 mg 1-tab po q hs. Effective date on medication bottle read 12/21/22. -Promethazine (for nausea) 25 mg 1-tab po q 6hrs as needed. Effective date on medication bottle read 12/19/22. -Duloxetine (for depression and anxiety) 60 mg 1 cap po q hs. Effective date on medication bottle read 06/16/22. -Vitamin C (helps immune system) 500 mg 1-tab po q day “I have been taking it since May 2022.” -Zinc (helps support immune system)50 mg 1-tab po q day “I have been taking it since May 2022.” -Vitamin A (important nutrient to vision, growth and immunity) 2500 mcg 1-tab po q day “I have been taking it since May 2022.” -Vitamin D3 (helps body absorb calcium)125mcg (5000 iu)1 tab q day “I have been taking it since May 2022.” -Aleve (for pain) 220 mg 2 tabs q am and 2 tabs q pm “I have been taking it for a while.” -Trulicity/Tresiba Flextouch (for diabetes) 100 units/ ml 12 units qhs “I have been using it for 4 or 5 years.” Patient #2's clinical record included an agency form titled "Cert Period: 11/17/2022- 01/15/2023 Medication Record " signed by RN F on 11/14/22. The form did not include documented evidence that RN F updated the Medication Record to include medications patient was currently taking and medications that have been discontinued. During an interview on 01/05/23 at 3:48 p.m. with the DON Surveyor AA presented the above findings. After review of Patient #2's clinical record, the DON acknowledged that the Medication Record had not been updated. Surveyor AA asked DON if the medication profile was accurate. DON stated, “according to what you are telling me no.” 2. Review of Patient #10’s medications during a Home Visit conducted on 01/04/23 at 11:06 a.m. thru 12:15 p.m. , medication bottles were observed as follows: - Acetaminophen (for pain) 500 mg 2 tabs bid prn po - Amlodipine (for blood pressure) 10 m 1 ab daily po - ASA (thins the blood) 81 mg 1-tab daily po - Cetirizine (for allergies) 10 mg 1-tab daily po - Duloxetine (for depression and anxiety) 60 mg 1-tab daily po - Iron (for anemia) 65 mg 1-tab daily po - Lantus (for diabetes) 100 units/ml 15 units daily sq - Pepcid (for heartburn) 20 mg 1-tab daily po -Prazosin (for blood pressure) 2mg 1-tab qhs po -Sevelamer (for blood pressure) 800 mg 3 tabs daily po -Escitalopram (for depression and anxiety) 1-tab po once daily effective date on bottle read 12/03/22. “I (patient #10) have been taking that for several years.” -Carvedilol (for blood pressure or heart failure) 25 mg 1-tab po BID. “I have been taking it for a long time, years.” -Stool Softener (for constipation)100 mg 1 cap po twice a day. “It’s been about a month or so.” -Atorvastatin (for cholesterol) 8 mg 1-tab po at bedtime effective date on bottle read 12/03/22. “I have been taking it for several years.” - Tamsulosin (for enlarged prostate) 0.4mg 1 cap one a day at 1900 effective date on bottle read 12/03/22. Patient #10 stated he had taken medication for years. - Finasteride (for enlarged prostate) 5 mg 1-tab once a day effective date on bottle read 12/03/22. Patient #10 stated he had taken medication for years. - Lisinopril (for blood pressure) 1 mg 1- tab BID po effective date on bottle read 12/03/22. - Tramadol (for pain) 50 mg 1-tab po q 6hrs prn effective date on bottle read 12/22/22. -Oxycodone (for pain) 5 mg i- or ii-tabs q six hours as needed effective date on bottle read 12/22/22. - Clonidine (for blood pressure) 0.1 mg i tab po 3 times a day as needed SBP is >160 effective date on bottle read 12/03/22. -Lispro (for diabetes) 1 unit/0.01 ml (Humalog) mild sliding scale at bedtime: 151 to 200=1 unit; 201 to 250= 2 units; 251-300=3 units; 301 to 350=4 units; 351 to 399= 5 units 400 or above Call= DR. (Patient #10’s spouse present a form titled “Discharge Reconciliation Report for Patient #10, Hospital Y” and stated patient currently on lispro) [medication not presented to surveyor.] - Lispro (for diabetes) 1 unit/0.01 ml (Humalog) mild sliding scale before meals morning at evening: 151 to 200=2 unit; 201 to 250= 4 units; 251-300=6 units; 301 to 350=8 units; 351 to 399= 10 units 400 or above Call =DR. (Patient #10’s spouse present a form titled “Discharge Reconciliation Report for Patient #10, Hospital Y” and stated patient currently on lispro) [medication not presented to surveyor.] Review of Patient #10's clinical record included a POC signed and dated by DON on 12/03/22 for the Certification period of 12/03/22 to 01/31/23 with a primary diagnosis of Non-ST elevation (NSTEMI) myocardial infarction (a lesser severe heart attack causing less damage to the heart). The POC included a SN visit frequency of three times a week for two weeks. PT one visit for one week to evaluate and treat for restorative therapy effective week of 12/04/22 and OT one visit for one week to evaluate and treat for restorative therapy effective week of 01/01/23. Further review of the POC for the Certification period of 12/03/22 to 01/31/23 revealed no documented evidence that it included the following medications: -Escitalopram (for depression and anxiety) 1-tab po once daily effective date on bottle read 12/03/22. “I (patient #10) have been taking that for several years.” -Carvedilol (for blood pressure or heart failure) 25 mg 1-tab po BID. “I have been taking it for a long time, years.” -Stool Softener (for constipation)100 mg 1 cap po twice a day. “It’s been about a month or so.” -Atorvastatin (for cholesterol) 8 mg 1-tab po at bedtime effective date on bottle read 12/03/22. “I have been taking it for several years.” - Tamsulosin (for enlarged prostate) 0.4mg 1 cap one a day at 1900 effective date on bottle read 12/03/22. Patient #10 stated he had taken medication for years. - Finasteride (for enlarged prostate) 5 mg 1-tab once a day effective date on bottle read 12/03/22. Patient #10 stated he had taken medication for years. - Lisinopril (for blood pressure) 1 mg 1- tab BID po effective date on bottle read 12/03/22. - Tramadol (for pain) 50 mg 1-tab po q 6hrs prn effective date on bottle read 12/22/22. -Oxycodone (for pain) 5 mg i- or ii-tabs q six hours as needed effective date on bottle read 12/22/22. - Clonidine (for blood pressure) 0.1 mg i tab po 3 times a day as needed SBP is >160 effective date on bottle read 12/03/22. -Lispro (for diabetes)1 unit/0.01 ml (Humalog) mild sliding scale at bedtime: 151 to 200=1 unit; 201 to 250= 2 units; 251-300=3 units; 301 to 350=4 units; 351 to 399= 5 units 400 or above Call= DR. (Patient #10’s spouse present a form titled “Discharge Reconciliation Report for Patient #10, Hospital Y” and stated patient currently on lispro) [medication not presented to surveyor.] - Lispro (for diabetes) 1 unit/0.01 ml (Humalog) mild sliding scale before meals morning at evening: 151 to 200=2 unit; 201 to 250= 4 units; 251-300=6 units; 301 to 350=8 units; 351 to 399= 10 units 400 or above Call =DR. (Patient #10’1 spouse present a form titled “Discharge Reconciliation Report for Patient #10, Hospital Y” and stated patient currently on lispro) [medication not presented to surveyor.] Patient #10's clinical record included an agency form titled "Cert Period: 12/03/2022- 01/31/2023 Medication Record " signed by RN F on 11/14/22. The form did not include documented evidence that DON updated the Medication Record to include medications patient was currently taking and medications that have been discontinued. During an interview on 01/05/23 at 4:00 p.m. with the DON Surveyor AA presented the above findings. After review of Patient #10's clinical record, the DON acknowledged that the Medication Record had not been updated. Surveyor AA asked DON if the medication profile was accurate. DON stated, “What you are saying, no, but we haven’t had a chance to see him. They have refused visits.” Review of the agency's policy manual included a policy titled "Medication List and Monitoring” 97.300;484.55(c) with no revision date. The policy revealed, in part: “…All patients will have a drug regimen review performed upon admission to Agency, upon recertifications, and as needed, to accommodate changes in the patient’s medication list… A medication profile/list will be maintained on all patients/clients.… Medication monitoring will include appropriate data/information to develop an accurate patient/client medication history and a current, complete medication profile…”

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: (This is a continuing deficiency previously cited at G-710 on 02/05/20.) Based on record review and interview, the agency skilled nurse failed to ensure the services were provided as ordered in the POC for 4 of 9 Active Patients (#6, #7, #9 and #10) whose records were reviewed. This failure could place the agency's patients at risk of receiving inadequate care and services and could place the patients at risk of negative outcomes. The findings include: 1. Review of Patient #6’s record revealed a POC for the period of 10/14/22 to 12/12/22 with a diagnosis of Hypokalemia (low potassium levels. Potassium is a mineral that is needed by the body so that it may work normally. Low potassium levels may cause muscle cramps, weakness, constipation, fatigue, and most importantly it can affect the rhythm to the heart) and a skilled nurse visit frequency of two visits a month for two months and one visit a month for 1 month. Review of Patient #6’s record included a Start of Care Comprehensive Assessment that was signed and dated by RN E on 10/14/22. Continued review of Patient #6’s record failed to include documented evidence the nurse followed the orders to perform two SN visits for the month of October 2022 as per the POC. During an interview on 01/03/21 at 3:21 p.m. with DON, the surveyor presented the above findings. After review of the documents presented, the Don acknowledged the frequency was not followed per the POC. DON stated, “I think we should have a missed visit. Surveyor asked Don if the frequency of two visits a month for two months was followed for October. Don stated, “no.” 2. Review of the of Patient 7’s record revealed a POC for the period of 10/27/22 to 12/25/22 with a primary diagnosis of Anemia (a condition in which the blood doesn’t have enough healthy red blood cells to carry oxygen to the body leading to weakness, feeling dizzy, lightheaded, or feeling very tired. It may also cause a fast heartbeat) and a skilled nurse frequency of three visits a month for one month and two visit a month for one month. Review of Patient #7’s record revealed an SN note signed and dated by LVN J on 11/03/22. Continued review of Patient #7’s record revealed an SN note signed and dated by LVN J on 11/14/22. Further review of Patient #7’s record revealed an SN note signed and dated by LVN J on 11/28/22. Review of Patient #7’s record failed to include documented evidence the nurse followed the orders to perform three SN visits for the month of October and two visits for the month of November as per the POC. During an interview on 01/03/23 at 3:26 p.m. with DON, the surveyor presented the above findings. After review of the documents presented, DON acknowledged the frequency was not followed as per POC. Surveyor asked if the frequency of three visits a month for one month were followed as per POC in October. DON stated, “no it should have been effective November.” Surveyor then asked if the frequency of two visits a month for one month was followed as per POC. DON stated, “no.” 3. Review of the of Patient 9’s record revealed a POC for the period of 10/17/22 to 12/25/22 with a primary diagnosis of Hyperlipidemia (a condition where there is high levels of fat in the blood that can cause a heart attack or stroke due to the decrease in blood flow to the body) and a skilled nurse frequency of three visits a month for one month, two visit a month for one month, and one visit a month for one month. Review of Patient #9’s record revealed an SN note signed and dated by LVN J on 10/18/22. Review of Patient #9’s record revealed an SN note signed and dated by LVN J on 10/25/22. Review of Patient #9’s record revealed an SN note signed and dated by LVN J on 11/01/22. Continued review of Patient #9’s record revealed an SN note signed and dated by LVN J on 11/14/22. Further review of Patient #9’s record revealed an SN note signed and dated by LVN J on 11/28/22. Review of Patient #9’s record failed to include documented evidence the nurse followed the orders to perform three SN visits for the month of October and two visits for the month of November as per the POC. During an interview on 01/03/23 at 3:30 p.m. with DON, the surveyor presented the above findings. After review of the documents presented, DON acknowledged the frequency was not followed as per POC. Surveyor asked if the frequency of three visits a month for one month were followed as per POC in October. Surveyor then asked if the frequency of two visits a month for one month was followed for November. DON stated, “no.” 4. Review of the of Patient #10’s record revealed a POC for the period of 12/03/22 to 01/31/23 with a primary diagnosis of NON-ST elevation (NSTEMI) Myocardial infarction (a lesser severe heart attack causing less damage to the heart) and a skilled nurse frequency of three visits a week for two weeks. Review of Patient #10’s record revealed a Start of care Comprehensive Assessment note signed and dated by DON on 12/03/22. Review of Patient #10’s record revealed a form titled “[Agency Name] Communication Note, Missed Visit note” signed and dated by LVN H on 12/16/22. Review of Patient #10’s record revealed a form titled “[Agency Name] Communication Note, Missed Visit note” signed and dated by LVN H on 12/22/22. Review of Patient #10’s record failed to include documented evidence the nurse followed the orders to perform three SN visits for two weeks. During an interview on 01/04/23 at 8:52 a.m. with DON, the surveyor presented the above findings. After review of the documents presented, DON acknowledged the frequency was not followed as per POC. Surveyor asked if the frequency of three visits a week for two weeks were followed as per POC DON stated, “we didn’t follow the frequency.” Review of the agency's policy and procedure manual revealed a policy titled "Plan of Care (POC)" 558.294;558.297n558.281 (11) dated 01/01/22. It read in part: "…XV. Services are furnished in accordance with the POC and under the supervision and direction of a qualified, designated RN.” Review of the agency's policy and procedure manual revealed a policy titled "(Supervising Nurse)" 97.243,487.14 dated 01/13/18. It read in part: "…Procedure: 1. The responsibilities of the Supervising Nurse include but are not limited to: …H. Ensuring that a patient/client plan of care or care plan is executed as written” …

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure skilled professionals completed clinical notes were accurate and complete for 1 of 9 Active Patients (#2) and 1 of 3 Discharged Patients (#12) whose records were reviewed. This failure prevents the agency from ensuring client services are provided and the needs are met and could place all agency patients as risk of harm. The findings included: 1. Review of Patient #2’s record revealed a POC for the period of 09/08/22 to 11/16/22 with a diagnosis Type 2 diabetes (Diabetes Mellitus is condition where the insulin your pancreas makes can’t work properly or can’t make enough insulin, causing high blood sugar levels) with diabetic peripheral angiopathy (a disease caused by high blood sugars affecting the blood vessels) with gangrene (a condition that occurs when tissue dies turning the body part black or purplish due to decrease circulation). With SN visit frequency of three visits a week for eight weeks, then one visit a week for one week. Review of Patient #2’s record revealed a form titled “[Agency Name] Communication Note, Covid-19” signed and dated by LVN H on 10/31/22. Continued review of Patient #2’s record revealed a form titled “[Agency Name] Communication Note, Covid-19” signed and dated by LVN H on 11/05/22. Review of the record failed to reveal documentation that SN notes dated 10/31/22 and 11/05/22 were in the clinical record within 14 days. During an interview concurrent with record review on 01/03/23 at 3:04 p.m. with DON, Surveyor AA presented the above findings. After review of the documents presented, the DON acknowledged the SN notes were not in the clinical record within 14 days. DON stated, “no.” 2. Review of Discharged Patient #12’s record revealed a POC for the period of 08/19/21 to 10/17/21 with a diagnosis of Pressure Ulcer other site (also called a bed sore, injury to the skin caused by staying in the same position for a very long time/ hours), stage 3 (open area/sore gets worse, a crater is created, and the fat is seen due to how deep the wound is. At this point the patient is at a higher risk for infection). Stage With an SN visit frequency of two visits a week for one week, then three visits a week for eight weeks. Review of Discharged Patient #12’s record revealed a form titled “[Agency Name] Communication Note” “Missed Visit Note” dated 09/08/21, 09/13/21 and 10/08/21. Review of the record revealed no documented evidence that the Missed Visit Notes dated 09/08/21, 09/13/21 and 10/08/21 were completed. During an interview concurrent with record review on 01/05/23 at 4:15 p.m. with DON, Surveyor AA presented the above findings. After review of the documents presented, the DON acknowledged the Missed Visit Notes dated 09/08/21, 09/13/21 and 10/08/21 were incomplete. DON stated, “they are not signed (missed visit notes).” Review of the agency's policy manual included a policy titled "Clinical Note” 97.031 with no revision date. The policy revealed, in part: “…To have a complete, accurate, legal document recording direct contact with a patient…Clinical notes are incorporated into the client record on a timely basis but no later than fourteen business days after submitted. …”