Every finding on record at Apc Home Health Service Inc

Purpose of Visit: To conduct a Re-Certification Survey. An entrance conference was conducted on 09/04/25. Census: Licensed & Certified- 70 Licensed Home Health Services -0 Total Census: 70 The Agency was in compliance with no deficiencies/violations cited.

Purpose of Visit: To conduct a Re-Certification Survey. An entrance conference was conducted on 09/04/25. Census: Licensed & Certified- 70 Licensed Home Health Services -0 Total Census: 70 Abbreviations: Adm-Administrator Alt Adm- Alternate Administrator DON-Director of Nurses FNP- Family Nurse Practitioner OASIS- Outcome and Assessment Information Set (data collected as part of the comprehensive assessment) POC- Plan of Care PT-Physical Therapy/ Physical Therapist RN- Registered Nurse

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 record review and an interview, the agency failed to ensure transfer summaries were provided to the primary care practitioner or other health care professional responsible for 2 of 2 Discharged Patients (#6 & #7) whose records were reviewed. This failure places agency patients at risk of harm for lack of adequate and appropriate continuity of care post transfer/discharge. The Findings Included: Review of the agency's policy manual included a policy titled, "Medical Record Content" IM.25 with a reviewed date of 07/05/25. The document revealed in part, …. "9. 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/client after discharge from the Agency (if any) within five business days of the patient’s/clients’ discharge…” … Review of Discharged Patient #6’s clinical record included a Home Health Certification and Plan of Care signed by Alt Adm/DON on 08/07/24 for the certification period of 08/07/24 to 10/05/24 with a Principal diagnosis of Pressure ulcer of right upper back, stage 3 (a deep wound that can resemble a hole or crater that affects the top two layers of the skin as well as fatty tissue). The POC included a skilled nurse visit frequency of one visit a week for one week, then two visits a week for three weeks and 2 visits as needed…” … Review of discharged Patient #6's clinical record revealed a form titled “OASIS-E Discharge (Non-Billable) that was signed and dated by the Alt Adm/DON on 09/05/24. Continued review of the OASIS-E Discharge revealed in part, … “Physician notified of discharge prior to discharge date…” … Review of a word document that was presented to the Surveyor, that did not include a patient’s name was identified as the documentation date of when the discharge summary was hand delivered. Continued review of this form revealed that the discharge summary was hand delivered to the FNP’s office on 09/19/24. Further review of Discharge Patient #6’s electronic record failed to reveal documented evidence that the discharge summary was sent to the primary care practitioner within 5 business days of being discharged. During an interview and record review on 09/10/25 at 3:20 p.m. with the Adm and Alt Adm/DON, the surveyor presented the above findings. The Alt Adm/DON was asked if the discharge summary was sent to the primary care practitioner or other health care professionals within 5 days of being discharged. The Alt Adm/DON stated, “no ma’am, it was sent when it was done by the clinician.” The Alt Adm/DON was then asked when the patient was discharged. Alt Adm/DON stated that the patient was discharged on 09/05/24 and that it was a nonbillable discharge. The surveyor asked when the discharge summary was delivered. The Alt Adm/DON stated it was delivered on 09/19/24. The Alt Adm/DON was then asked who was responsible for tracking discharge summaries. The Alt Adm/DON stated, “I am responsible. I notify the nurses daily. Past due documentation we bring them into the office.” The Alt Adm/DON was asked if RN F was brought in regarding late notes. The Alt Adm/DON stated, “no.” No reason was provided as to why RN F was not brought in for late documentation. During an interview on 09/11/25 around 10:38 a.m. with the Alt Adm/DON the Alt Adm/DON stated that RN F (out ill) stated that she prioritized the OASIS and that there would be a delayed response and nothing else would be affected. Review of Discharged Patient #7’s clinical record included a Home Health Certification and Plan of Care signed by RN F on 02/18/25 for the certification period of 02/21/25 to 04/12/25 with a Principal diagnosis of I/I (infection and inflammation) reaction due to indwelling urethral catheter (a thin flexible tube inserted in the urethra [the tube that carries the urine from the bladder out of the body] to drain urine from the body) The POC included a skilled nurse visit frequency of no visits for one week, then one visit a week for three weeks, then two visits as needed…” … Review of discharged Patient #7's clinical record revealed a form titled “OASIS-E Discharge (PT) that was signed and dated by PT L on 03/21/25. Continued review of the OASIS-E Discharge revealed in part, … “Physician notified of discharge prior to discharge date…” … Review of a document that was presented to the Surveyor on 09/10/25 revealed that the 486 (part of the plan of care that is used as a summary for the physician regarding patient information) was faxed on Monday, March 31,2025 at 1:54 p.m. for this patient. Continued review of this form revealed that the discharge summary was sent via fax on 03/31/25. Further review of Discharge Patient #7’s electronic record failed to reveal documented evidence that the discharge summary was sent to the primary care practitioner within 5 business days of being discharged. During an interview and record review on 09/10/25 at 2:51 p.m. with the Adm and Alt Adm/DON, the surveyor presented the above findings. The Alt Adm/DON was asked if the discharge summary was sent to the primary care practitioner or other health care professionals within 5 days of being discharged. The Alt Adm/DON stated, “no it was not, no good reason.” The Alt Adm/DON was then asked when the patient was discharged. Alt Adm/DON stated that the patient was discharged on 03/21/25 and it (discharge summary) was sent on 03/31/25. The Surveyor then asked what the agency’s process was regarding discharges and discharge summaries. The Alt Adm/DON stated that the schedular creates the OASIS and that he calls the patients the day before and informs them that they will be discharged. The nurse then goes out to do the assessment and lets him know that the agency will be discharging the patient. The Alt Adm/DON then stated that the nurses have 5 days to complete their documentation and that the discharge summary should be sent out within 5 days of discharge. The Alt Adm/DON stated that RN F completed the discharge summary on 03/31/25. The Surveyor asked who made sure the discharge summaries were sent within the 5 days of discharge. The Alt Adm/DON stated that himself, RN F, and Insurance Verification Clerk checked and made sure orders were sent out daily. The Alt Adm/DON then stated, “It looks like RN F sat on it (delayed completing the discharge summary)” During an interview and record review on 09/10/25 at 3:19 p.m. with the Adm and Alt Adm/DON present and RN F via conference call (due to being ill) was asked if the discharge summary was sent to the primary care physician or any other providers within 5 days of being discharged. RN F stated, “no, late documentation.” The Surveyor then asked how it could affect patient care if the discharge summary does not get sent to the physician and others providing services to the patient within the 5 days of discharge. RN F stated, “it will be a delayed response, nothing else would be affected.”

A Recertification Survey, Follow-Up to 10/18/19, and Follow-Up to 06/10/20 entrance conference was conducted on 10/10/22 with the Administrator and Alternate Administrator/Supervising Nurse at 8:53 a.m. Census: L&C [Licensed and Certified] - 85 LHH [Licensed Home Health] – 0 An exit conference was conducted on 10/14/22, with the administrator and alternate administrator/supervising nurse at 8:29 a.m. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Acronyms and Definitions: 1.) L&C – Licensed and Certified 2.) LHH – Licensed Home Health 3.) Hemodialysis Catheter - a medical tube inserted into a large vein which can be connected to a medical device used to cleanse the blood for individuals with kidney disease. 4.) OASIS - Outcome and Assessment Information Set 5.) ESRD - End Stage Renal Disease - a medical condition in which the kidneys do not function effectively to cleanse wastes from the blood. 6.) Renal Dialysis - a medical treatment in which the blood is run through a medical tube into a machine which cleanses the blood. 7.) Central Venous Catheter - a type of hemodialysis catheter. 8.) Blood Glucose Level - the amount of glucose or sugar in the blood. 9.) Type 2 Diabetes Mellitus - a medical condition in which the body cannot effectively regulate the amount of glucose or sugar in the blood. 10.) Hyperglycemia - high or elevated blood glucose. 11.) Fasting Blood Sugar - blood glucose level taken prior to eating. 12.) Random Blood Sugar - blood glucose level which does not have to be taken prior to eating. 13.) LVN – Licensed Vocational Nurse 14.) RN – Registered Nurse 15.) Peri-Wound - the area around the wound. 16.) SN – Skilled Nurse 17.) NS – Normal Saline 18.) Medihoney – a wound gel made of medical grade honey. 19.) Proximal – nearer to the center of the body. 20.) Cutaneous Abscess – a localized collection of pus in the skin. 21.) Cellulitis – a common bacterial skin infection which causes redness, swelling, and pain to the area. 22.) Gangrene - death of body tissues due to lack of blood flow or infection. 23.) Medial – toward the middle or center. 24.) Lateral – to the side of or away from the center of the body. 25.) Abdomen – stomach area 26.) C/O – complained of 27.) Tylenol #3 - a type of controlled pain medication. 28.) Meds – Medications 29.) MD – Medical Doctor 30.) BLE - bilateral – both sides – lower extremities – legs. 31.) Hypoglycemia – low blood glucose levels. 32.) Trulicity - a medication used to lower blood glucose levels. 33.) KCI transparent drape - a type of transparent wound dressing used with wound vacuum assisted closure devices. 34.) Wound Vacuum Assisted Closure Device – a medical device used to assist in wound healing. 35.) Black Foam - a type of absorbent wound dressing used with wound vacuum assisted closure devices. 36.) KCI V.A.C. Therapy Unit - a type of wound vacuum assisted closure device. 37.) @ - at 38.) 3 x week – three times a week 39.) Ace wrap – a type of bandage used to wrap wounds or injuries. 40.) Vac – wound vacuum assisted closure device. 41.) Hydrogen Peroxide - a type of cleansing solution used to treat or prevent infection. 42.) Mupirocin - a topical medication used to treat or prevent infection. 43.) Hydrofera Blue Tunneling Dressing - a type of wound dressing used to treat or prevent infection. 44.) N/S – normal saline 45.) Peri-rectal - the area surrounding the rectum. 46.) Sacrum – tailbone 47.) Non-stageable or Unstageable Pressure Injury/Ulcer – a pressure injury/ulcer which demonstrates with a full thickness skin/tissue loss in which the full extent of the wound cannot be determined because the wound is covered with dead tissue. 48.) Vashe Wound Solution - a topical solution used to cleanse wounds.

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 interview and record review, the agency failed to ensure each patient’s individualized plan of care included safety measures to protect against injury for 1 of 1 (Patient #4) patient reviewed who had a hemodialysis catheter [a medical tube inserted into a large vein which can be connected to a medical device used to cleanse the blood for individuals with kidney disease]. This failure could have resulted in harm to the patient related to agency staff utilizing the hemodialysis catheter in an unsafe manner. The findings included: Record review of the clinical record for Patient #4 included a start of care OASIS [Outcome and Assessment Information Set] assessment, dated 08/19/22, which indicated Patient #4 had diagnoses of ESRD [End Stage Renal Disease - a medical condition in which the kidneys do not function effectively to cleanse wastes from the blood] and dependence on renal dialysis [a medical treatment in which the blood is run through a medical tube into a machine which cleanses the blood]. The start of care OASIS assessment indicated the patient was on renal dialysis and had a central venous catheter [a type of hemodialysis catheter] to the right upper chest wall. Record review of the clinical record for Patient #4 included a plan of care, for the certification period of 08/19/22 – 10/17/22, which indicated the patient had diagnoses of ESRD and dependence on renal dialysis. The plan of care indicated the patient was to receive skilled nursing visits once a day for 14 days. The plan of care did not include safety measures to protect against injury related to the patient’s hemodialysis catheter in that the plan of care did not include documentation of the presence of, location of, who was to provide care to, and any restrictions on use of the hemodialysis catheter to ensure staff were aware of the presence of the hemodialysis catheter and did not use the catheter in an unsafe manner. During an interview conducted on 10/11/22 at 1:38 p.m., with the administrator and the alternate administrator/supervising nurse, the administrator said the agency did not specifically include documentation of the presence, location, or who would be responsible for the care of the hemodialysis catheter on the patient’s plan of care. The administrator said there was no harm to the patient related to this failure. The alternate administrator/supervising nurse said there could be potential harm to the patient related to the failure to include the information regarding safety measures to protect the patient against injury in relation to the hemodialysis catheter and the failure to document the presence of, location of, who was to provide care to the hemodialysis catheter and any restrictions related to the use of the hemodialysis catheter on the plan of care. The alternate administrator/supervising nurse the agency should have taken it one step further to include the documentation of this information on the plan of care to ensure the staff knew not to do anything with the patient’s hemodialysis catheter. Record review of the agency’s policy titled, “Plan of Care,” dated 01/01/22, indicated, “The individualized plan of care must specify the care and services necessary to meet the patient/client-specific needs as identified in the comprehensive assessment … The individualized plan of care must include … Safety measures to protect against injury …”

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 on 10/18/19 at G710 484.75(b)(3) Provide Services in the Plan of Care. Based on interview and record review, the skilled nurse failed to provide services ordered by the physician as indicated in the plan of care for 1 of 1 (Patient #13) patient reviewed with physician orders for the skilled nurse to check the patient’s blood glucose level [the amount of glucose or sugar in the blood] during visits if not already performed. This failure could have resulted in the agency missing evidence of an exacerbation [worsening] of a patient’s disease process and could impede the agency’s ability to monitor the patient for concerns related to the diagnosis of Type 2 diabetes mellitus. The findings included: Record review of the clinical record for Patient #13 included a plan of care, for the certification period of 03/04/22 – 04/28/22, which indicated the patient had a diagnosis of Type 2 Diabetes Mellitus [a medical condition in which the body cannot effectively regulate the amount of glucose or sugar in the blood] with hyperglycemia [high or elevated blood glucose]. The plan of care indicated the patient was to receive skilled nursing visits once a week for four weeks. The plan of care also indicated the skilled nurse was to provide “Assessment of patient with … Type 2 diabetes mellitus with hyperglycemia … SN [skilled nurse] to perform finger stick for fasting blood sugar [blood glucose level taken prior to eating]/random blood sugar [blood glucose level which does not have to be taken prior to eating] during visit if it has not been done …” Record review of the clinical record for Patient #13 included a skilled nurse’s note, dated 03/22/22, signed by LVN [Licensed Vocational Nurse] D, which did not indicate the skilled nurse assessed the patient with Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during this visit. Record review of the clinical record for Patient #13 indicated no skilled nurse visits were ordered or provided between 03/22/22 and 04/05/22. Record review of the clinical record for Patient #13 included a transfer summary, dated 04/05/22, which indicated Patient #13 was transferred to the hospital on 04/05/22 due to hyperglycemia and a fall. Record review of the clinical record for Patient #13 included a transfer OASIS which indicated the patient was transferred to the hospital on 04/05/22 due to hyperglycemia and a fall. Record review of hospital records for Patient #13 indicated the patient was admitted to the hospital on 04/05/22 with a diagnosis of hyperglycemia. During an interview conducted on 10/12/22 at 3:42 p.m. – 3:51 p.m., LVN D said she could not recall the visit on 03/22/22 with Patient #13. LVN D said she had reviewed her skilled nurse’s note for this visit and did not see the documentation to indicate she assessed the patient’s blood glucose level during this visit on the nurse’s note. LVN D said she does have a paper tablet she kept some notes on outside of the agency’s electronic patient record. LVN D said she shredded these tablets after a while, but she would check to see if she still had the one from this date. LVD D said she would let the surveyor know if she was able to find anything regarding the blood glucose level assessment for Patient #13 on 03/22/22 or not. During an interview conducted on 10/13/22 at 9:52 a.m. – 9:55 a.m., LVN D said she was not able to find any other documentation for Patient #13 regarding the visit she conducted with the patient on 03/22/22. LVN D said she kept yellow paper pads which she had some documentation on, but she could not locate the one for this visit. LVN D said she thought she must have shredded it. LVN D said she did review her skilled nurse’s note in the agency’s electronic medical record for Patient #13 for this visit. LVN D said she thought she did check the blood glucose level during this visit because she follows her plan of care, but she did not have the number for the blood glucose level to say what it was. LVN D said when there is an order on the plan of care to check the blood glucose level, she will document the blood glucose level on the nurse’s note. During an interview conducted on 10/13/22 at 10:37 a.m. – 11:05 a.m., with the administrator and the alternate administrator/supervising nurse, when asked if they would agree that assessment of the blood glucose level would be considered a necessary part of an assessment of a patient with a diagnosis of Type 2 diabetes mellitus, the alternate administrator/supervising nurse said, yes. The alternate administrator/supervising nurse said there could be potential harm to the patient in that the agency could miss evidence of an exacerbation [worsening] of a patient’s disease process. The alternate administrator/supervising nurse said she agreed it was fair to say the record would not be complete which could impede the agency’s ability to monitor the patient for concerns related to the diagnosis of Type 2 diabetes mellitus. During an interview conducted on 10/14/22 at 8:10 a.m. – 8:20 a.m., Patient #13 said she could not recall if the nurse had checked or assessed her blood glucose level on 03/22/22. Patient #13 said she had many things happening with her health and that of her family during that time frame and she could not recall what happened on 03/22/22 specifically. Record review of the agency’s policy titled, “Plan of Care,” dated 01/01/22, indicated, “Each patient/client must receive the home health services that are written in an individualized plan of care …”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on interview and record review, the skilled nurse failed to prepare clinical notes for 2 of 2 (Patient #3 and Patient #4) patients reviewed for whom the skilled nurse failed to document coordination of care with the physician. This failure resulted in the agency maintaining an incomplete clinical record and could result in the agency failing to maintain thorough communication regarding each patient. The findings included: Record review of the clinical record for Patient #3 included a plan of care, for the certification period of 08/28/22 – 10/26/22, which indicated the patient had diagnoses of cutaneous abscess [a localized collection of pus in the skin] of left lower limb and cellulitis [a common bacterial skin infection which causes redness, swelling, and pain to the area]. The plan of care indicated the patient was to receive skilled nurse visits twice a week for four weeks. The plan of care indicated the skilled nurse was to provide assessment of the patient with a cutaneous abscess of the left lower limb [Wound #1]. Record review of the clinical record for Patient #3 included a skilled nurse’s note, dated 09/22/22, signed by LVN D, which indicated during this visit LVN D noted the patient to have a new wound to the proximal [nearer to the center of the body] left upper thigh. The skilled nurse’s note indicated, “Patient with new wound proximal to wound #1 … Wound #2 … that appears like a pimple with a beige color on top that is closed with peri-wound [the area around the wound] slightly red. Patient reported to SN [skilled nurse] that ----------- [name of Patient #3’s physician] notice (sic) wound #2 yesterday during patient visit and instructed the nurse to clean it up with NS [normal saline] and apply medihoney [a wound gel made of medical grade honey] on it and cover it with gauze … To Wound #2 SN … cleansed with NS, patted dry with gauze and covered with 4x4 gauze and secured with tape.” The skilled nurse’s note did not indicate the skilled nurse coordinated care with the patient’s physician regarding Wound #2. Record review of the clinical record for Patient #3 included a skilled nurse’s note, dated 09/23/22, signed by LVN D, which indicated, “Wound #2 to proximal of wound #1 remains intact with whitish/beige color to top of wound … SN applies dry 4x4 gauze and secured with tape … SN called the wound care center to report to ---------- [name of Patient #3’s physician] of patient small wound to left upper thigh proximal. SN requesting wound care order, but Wound care was closed per voicemail message.” Record review of the clinical record for Patient #3 did not include wound care orders for Wound #2, the wound to the patient’s proximal left upper thigh first noted during the visit conducted on 09/22/22, documented above. Record review of the clinical record for Patient #3 did not include documentation of clinical notes to indicate the skilled nurse received any follow-up communication from the physician or made any further attempt to contact the physician regarding Wound #2 after the attempt documented on the skilled nurse’s note for the visit conducted on 09/23/22. During an interview conducted on 10/11/22 at 10:16 a.m. – 10:31 a.m., LVN D said on 09/22/22 the patient had a new wound, Wound #2. LVN D reviewed her skilled nurse’s note for the visit she conducted with Patient #3 on 09/22/22 and said she made a visit with Patient #3 the day after the patient had been seen by the physician at the wound care center. LVN D said the patient said the physician had seen Wound #2 on 09/21/22 and told the patient to have the nurse put Medihoney on it but did not write an order for this. LVN D said Wound #2 was a small pimple like wound. LVN D said Wound #2 was very close to Wound #1 and she thought the drainage from Wound #1 might have caused it, so she put gauze over it to protect it but did not apply the Medihoney because the agency did not have an order to apply Medihoney to Wound #2. LVN D said she did attempt to contact the physician during the visit conducted on 09/22/22 but did not receive a response. LVN D said she also called the following day. LVN D said she left 2 messages for the physician and then finally got a call back During an interview conducted on 10/11/22 at 10:55 a.m. – 11:01 a.m., LVN E said on 09/26/22 the wound care center contacted the agency after LVN D had attempted to contact them the previous week regarding Patient #3’s new wound and asked them to assess Wound #2 on 09/26/22 and let the wound care center know how it looked. LVN E said on 09/26/22 she spoke with the patient’s physician directly and he did not give any new orders for Wound #2 because it was already scabbed over. LVN E said 09/26/22 was the first time she spoke with the physician’s office regarding Patient #3’s new wound but she did not know if LVN D or anyone else at the agency had spoken with them prior to this. During an interview conducted on 10/11/22 at 12:03 – 12:30 p.m., with the administrator and the alternate administrator/supervising nurse, the administrator said the agency has a policy on coordination of care which they use for general guidelines for coordinating care. When asked when Patient #3’s physician was first notified of the new wound, Wound #2, first identified on 09/22/22, by the skilled nurse, the alternate administrator/supervising nurse said the staff did not document this. The administrator also said the staff did not document this. The administrator said this should have been documented by the nurse in the comments section of the skilled nurse’s note. The administrator said it was not documented there. The administrator said it is the agency’s policy and procedure for staff to document communication with the physician and attempts to contact the physician. When asked if there was any actual or potential harm related to the nurse’s failure to complete clinical notes to document communication with the physician, the alternate administrator/supervising nurse said there was actual harm due to a lack of communication. Record review of the clinical record for Patient #4 included a plan of care, for the certification period of 08/19/22 – 10/17/22, which indicated the patient had diagnoses of encounter for surgical aftercare following surgery on the digestive system, gangrene [death of body tissues due to lack of blood flow or infection], traumatic wounds to the right thumb, right second finger, right third finger, right fourth finger, right great toe, right second toe, right third toe, right fourth toe, right fifth toe, left foot, left heel medial [toward the middle or center], left foot lateral [to the side of or away from the center of the body], and a surgical wound to the abdomen [stomach area]. The plan of care indicated the patient was to receive skilled nursing visits once a day for fourteen days. The plan of care indicated, “SN to assess pain level and effectiveness of pain medications and current pain management therapy every visit.” Record review of the clinical record for Patient #4 included a skilled nurse’s note, dated 09/20/22, signed by LVN D, which indicated, “Patient verbalized a pain score of 10 on a pain scale of 0-10 … Pain Intensity: 10 Severe … Patient c/o [complained of] pain to toes on a pain scale of 0-10 patient verbalized 10. Patient has completed the Tylenol #3 [a type of controlled pain medication] that was prescribed last month … SN called the wound care center to report to ---------- [name of Patient #4’s physician] and left message … to report patient c/o pain score of 10 to toes and does not having (sic) any pain medication for pain.” Record review of the clinical record for Patient #4, from 09/20/22 – 10/07/22, did not include documentation of any further coordination or communication with the physician regarding Patient #4’s complaint of pain and lack of pain medications. Record review of the clinical record for Patient #4 did not include any new orders for pain medications after 09/20/22. Record review of the clinical record for Patient #4 included a skilled nurse’s note, dated 10/07/22, signed by RN G, which indicated, “Patient reports pain of 10 on 0-10 pain scale … Pain Intensity: 10 Severe … Patient reports pain with slightest touch, requesting pain meds [medications], states has texted MD [Medical Doctor] but has not gotten response. SN contacted MD office at 1500, office closed for the day, message left on voicemail … Patient reports pain to BLE [bilateral – both sides – lower extremities – legs] of 10 on 0-10 pain scale and requesting pain medication, currently only taking Tylenol 500mgs as needed, which is only providing minimal relief … SN notified MD office but office closes early on Fridays; SN to follow-up on Monday during office hours.” During an interview conducted on 10/12/22 at 10:21 a.m. – 10:31 a.m., RN G said when they contacted the physician about the patient’s complaints of pain the physician did not respond and did not call back. RN G said that even if she told the physician’s office it was their second or third attempt to contact the physician about the issue the physician’s office staff just said ok and that the physician was aware. When asked if there was any documentation of attempts to follow-up with the physician after a message regarding the patient’s complaint of pain and request for pain medications was made, RN G said she thought she wrote a communication note on Monday 10/10/22 [20 days after the first documented complaint of pain at a 10] to follow-up as she had not received a response from the call made on 10/07/22. RN G said she could not say if there was any documentation in the clinical record between 09/20/22 and 10/07/22 regarding attempts to follow-up with the physician regarding the patient’s complaint of pain. RN G said when attempting to contact a physician regarding a patient concern if they are unable to reach the physician and must leave a message, they will call back later to make sure they speak with someone. RN G said the first time she had seen the patient herself was on 10/07/22. RN G said she is the patient’s RN case manager but if she does not do the patient’s start of care visit, she usually does not see the patient until it is time to do a RN re-evaluation, or the patient is discharged. RN G said on Monday [10/10/22] she spoke with the physician’s office regarding the patient’s complaint of pain and the staff member at the physician's office told her she would let the physician know. RN G said per the agency’s policy and procedure agency skilled nurses should document communication with the physician and attempts to communicate with the physician. RN G said if the skilled nurse speaks with the physician during the visit the documentation of this communication would be on the skilled nurse’s note and if the communication took place before or after the visit the skilled nurse would document the communication on a communication note. During an interview conducted on 10/12/22 at 10:58 a.m. – 11:15 a.m., LVN D said during the visit she conducted with Patient #4 on 09/20/22 the patient complained of pain at a level of 10. LVN D said she did call the physician regarding this, and the physician did not want to give the patient anything for pain. LVN D said she spoke to someone at the physician’s office, and they did not want to prescribe the patient pain medications. When asked if she had documented in the clinical record the follow-up communication with the physician where she was able to speak with the physician’s office and the physician declined to give any new orders related to the patient’s complaint of pain, LVN D reviewed the clinical record and then said she did not see any documentation of this other than what she had documented on her skilled nurse’s note for 09/20/22 which indicated she had called the physician and left a message. LVN D said per the agency’s policy and procedure the skilled nurse should document communication with the physician and attempts to communicate with the physician. LVN D reviewed the clinical record for Patient #4 and said she did not see documentation of this. LVN D said she did not recall if she had documented anything regarding the follow-up or other attempts to contact the physician regarding the patient’s complaint of pain or not. LVN D said the agency’s policy and procedure is to document these types of things on the skilled nurse’s note if the communication occurs while she is at the patient’s home and if she is not at the patient’s home when the communication occurs to document it on a communication note. During an interview conducted on 10/13/22 at 10:37 a.m. – 11:05 a.m., the administrator and the alternate administrator/supervising nurse said there could be potential for harm to patients related to the skilled nurse’s failure to prepare clinical notes regarding communication with the physician, follow-up with the physician, and attempts to communicate with the physician in that the record would be incomplete and there would be a lack of thorough communication in the record. The surveyor attempted to contact the physician for Patient #3 and Patient #4 on 10/13/22 at 4:36 p.m. A recorded message indicated the office was closed for the day. There was no way to leave a message. The surveyor contacted the office of the physician for Patient #3 and Patient #4 on 10/14/22 at 8:03 a.m. The surveyor left a message requesting a return phone call at the number for the physician’s nurse. There was no return phone call received from the physician’s office prior to the end of the survey. Record review of the agency’s policy titled, “Monitoring Patient Care/Coordination of Care,” dated 08/01/20, indicated, “When other organizations are involved in the patient’s/client’s care, Agency staff members will notify them of significant changes in the patient’s/client’s overall care. This communication will be documented in the medical record.”

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: This is a continuing deficiency previously cited on 10/18/19 at G1012 484.110(a)(1). Based on interview and record review, the agency failed to ensure each patient’s clinical record included the patient’s current comprehensive assessment, including all the assessments from the most recent home health admission, for 3 of 6 (Patient #9, Patient #13, and Patient #15) patients reviewed with a diagnosis of Type 2 Diabetes Mellitus and physician orders for the skilled nurse to assess the patient with this diagnosis. This failure resulted in the patients' clinical records being incomplete and could result in the agency missing evidence of an exacerbation [worsening] of a patient’s disease process and could impede the agency’s ability to monitor the patient for concerns related to the diagnosis of Type 2 diabetes mellitus and to report to the physician if the blood glucose level was outside of the parameters established on the plan of care. The findings included: Record review of the clinical record for Patient #9 included a plan of care, for the certification period of 08/27/22 – 10/25/22, which indicated the patient had a diagnosis of Type 2 diabetes mellitus. The plan of care indicated the patient was to receive skilled nursing visits once a week for one week, six times a week for one week and then three times a week for two weeks. The plan of care indicated, “Assessment of patient with … Type 2 diabetes mellitus … Notify physician of Fasting blood sugar greater than (>) 250 or less than () 350 or less than ( Record review of the clinical record for Patient #9 included skilled nurse’s notes, dated 08/28/22, 08/29/22, 09/01/22, 09/07/22, 09/09/22, 09/12/22, 09/14/22, 09/16/22, 09/19/22, 09/21/22, and 09/23/22, signed by LVN D, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during these visits. Record review of the clinical record for Patient #9 included a skilled nurse’s note, dated 09/05/22, signed by LVN E, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during this visit. Record review of the clinical record for Patient #9 included a skilled nurse’s note, dated 09/28/22, which indicated on this date the skilled nurse assessed Patient #9’s blood glucose level and determined it to be a fasting blood glucose level of 270 [outside of the parameters set on the plan of care to report to the physician, indicating the blood glucose level was elevated during this visit]. Record review of the clinical record for Patient #9 included a skilled nurse’s note, dated 10/01/22, signed by LVN D, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during this visit. During an interview conducted on 10/12/22 at 10:48 a.m., with LVN E, when asked if she had assessed or obtained Patient #9’s blood glucose level during the visit she conducted with the patient on 09/05/22, LVN E said the staff only check the blood glucose level if the plan of care specifically says to check the blood glucose level. LVN E said the procedure for most patients is to check the blood glucose level only if the patient shows signs of hyperglycemia or hypoglycemia [low blood glucose levels] or the patient requests for the nurse to check the blood glucose level. When asked if she would assess the blood glucose level in another way, such as by asking the patient what the blood glucose level was when she conducted skilled nursing visits, LVN E said, yes, she would usually ask. LVN E said she did not recall this specific visit. LVN E said if the patient reports a blood glucose level result to her, she will document this on the skilled nurse’s note. LVN E said during visits she will ask the patient if he has checked his blood glucose level and if he has not, she will ask if he wants her to check it. LVN E said she could not recall the patient’s response during when asked this question during the visit conducted on 09/05/22. During an interview conducted on 10/12/22 at 10:58 a.m. – 11:15 a.m., LVN D reviewed the above documented skilled nurse’s notes for visits she conducted with Patient #9 and said her normal practice is to always ask the patient if s/he had checked his/her blood glucose level if they are diabetic. LVN D said sometimes the patient will report the blood glucose level number and other times the patient would say that he didn’t recall what it was. LVN D said sometimes the patient would say he checked it and it was normal. When asked if she would document this in the clinical record if the patient reported he had checked his blood glucose level and it was normal or that he couldn’t recall the number, LVN D said she would only document if there was something abnormal reported or observed. When asked if she would document anything in the clinical record to indicate that she had assessed the patient’s body systems and disease processes, including the Type 2 diabetes mellitus, and assessed to determine that the blood glucose levels were within the parameters established on the patient’s plan of care, LVN D said she would only document something if she observed or if the patient reported something abnormal. When asked what the agency’s policy and procedure was regarding documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus, LVN D said she did not have the policy and procedure in front of her right now and could not say. When asked if the agency had provided her with any education or instruction on how to document to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus, LVN D said, yes, and said she had been instructed to only document when something abnormal was observed or reported. LVN D said she did ask the patient about his blood glucose level each visit. During an interview conducted on 10/12/22 at 1:09 p.m., with LVN D, when asked if Patient #9 kept a log of his blood glucose levels in his home, LVN D said she had never seen one. LVN D said she did not review a log of the patient’s blood glucose levels during visits and said she just asked the patient about his blood glucose levels. The surveyor attempted to contact Patient #9 on 10/13/22 at 8:46 a.m. and on 10/13/22 at 12:28 p.m. There was no answer to either attempt. A recorded message indicated the mailbox was full and there was no way to leave a message. Record review of the clinical record for Patient #13 included a plan of care, for the certification period of 09/25/22 – 11/23/22, which indicated the patient had a diagnosis of Type 2 diabetes mellitus. The plan of care indicated the patient was to receive skilled nursing visits twice a week for two weeks, then once a week for one week. The plan of care indicated, “Assessment of patient with … Type 2 diabetes mellitus … Notify physician of Fasting blood sugar greater than (>) 250 or less than () 350 or less than ( Record review of the clinical record for Patient #13 included skilled nurse’s notes, dated 09/28/22 and 10/03/22, signed by LVN D, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during these visits. Record review of the skilled nurse’s note, dated 09/28/22, signed by LVN D, also indicated the patient had started a new medication, Trulicity [a medication used to lower blood glucose levels] as of 09/28/22. During an interview conducted on 10/12/22 at 3:42 p.m. – 3:51 p.m., with LVN D, when asked if she completed an assessment of Patient #13 to include an assessment of the patient’s blood glucose level during the visits conducted with the patient on 09/28/22 and 10/03/22, LVN D reviewed her notes for these visits and said she did not document the assessment of the blood glucose levels on these visits but she did recall the patient’s family member told her the patient’s blood glucose level on 09/28/22 was 106 fasting. LVN D said the patient did have a new medication for Trulicity on this date. When asked if the Trulicity had been added to the patient’s medication regimen because her blood glucose levels had been elevated, LVN D said she did not think the patient’s blood glucose levels had been elevated as the patient’s family member said the blood glucose levels had been good. LVN D said on 10/03/22 she thought the patient’s family member said the patient’s blood glucose level on that date was 128. LVN D said she did not document the assessment of the patient’s blood glucose levels on her skilled nurse’s note, but she remembered them. LVN D said she did not document the assessment of the patient’s blood glucose levels on 09/28/22 and 10/03/22 because she does not document this unless there is something abnormal as discussed in the previous interview regarding Patient #9. During an interview conducted on 10/14/22 at 8:10 a.m. – 8:20 a.m., with Patient #13, when asked if the nurse asked her about her blood glucose levels during the visits conducting after her admission to the agency on 09/25/22, Patient #13 said, yes. Record review of the clinical record for Patient #15 included a plan of care, for the certification period of 03/16/22 – 05/14/22, which indicated the patient had a diagnosis of Type 2 diabetes mellitus. The plan of care indicated the patient was to receive skilled nurse visits twice a week for one week, three times a week for one week, and then twice a week for one week. The plan of care indicated, “Assessment of patient with … Type 2 diabetes mellitus … Notify physician of Fasting blood sugar greater than (>) 250 or less than () 350 or less than ( Record review of the clinical record for Patient #15 included skilled nurse’s notes, dated 03/18/22, 03/21/22, 03/23/22, 03/25/22, 04/01/22, 04/04/22, 04/06/22, 04/08/22, 05/01/22, 05/07/22, and 05/08/22, signed by LVN I, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during these visits. Record review of the clinical record for Patient #15 included skilled nurse’s notes, dated 03/28/22, 03/30/33, and 05/06/22, signed by the alternate supervising nurse, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during these visits. Record review of the clinical record for Patient #15 included skilled nurse’s notes, dated 05/02/22, 05/03/22, 05/04/22, 05/05/22, 05/09/22, 05/10/22, and 05/11/22, signed by LVN K, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during these visits. Record review of the clinical record for Patient #15 included a recertification OASIS, dated 05/13/22, signed by the alternate supervising nurse, which did not include documentation to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during this visit. The surveyor attempted to contact Patient #15 on 10/13/22 at 8:55 a.m. and on 10/13/22 at 10:08 a.m. There was no answer to either attempt. A voicemail message was left requesting a return phone call on both attempts. There was no return phone call received from Patient #15 prior to the end of the survey. During an interview conducted on 10/13/22 at 9:28 – 9:32 a.m., with the alternate supervising nurse, when asked if he assessed the patient’s blood glucose levels during each skilled nurse visit as part of the assessment of a patient with a diagnosis of Type 2 diabetes mellitus for Patient #15, the alternate supervising nurse said if there was an order on the plan of care to check the blood glucose level, he would check it. The alternate supervising nurse said if there was not a specific order to check the blood glucose level on the plan of care, he would ask the patient if they had checked their blood glucose level and would ask if there was anything abnormal or if there were signs and symptoms of hypoglycemia or hyperglycemia. The alternate supervising nurse said if the patient didn’t report anything unusual, they were usually good. The alternate supervising nurse said he would ask the patient about the blood glucose level every visit. The alternate supervising nurse said he does not usually document that he assessed the blood glucose level or what the reported/reviewed blood glucose level was unless it was abnormal. The alternate supervising nurse said Patient #15 had a privately paid caregiver and this privately paid caregiver kept a log of the patient’s blood glucose levels. The alternate supervising nurse said that he would review the blood glucose log during visits. The alternate supervising nurse said the agency’s policy and procedure was to only document the assessment of the patient’s blood glucose level if there was something abnormal. When asked if he would usually document the assessment of the patient’s blood glucose level, either obtained or reviewed/asked of the patient, for the recertification visit, the alternate supervising nurse said it would depend on if the patient had a diagnosis of diabetes mellitus, what the patient was skilled for services for, and if the diabetes was stable or not. During an interview conducted on 10/13/22 at 8:50 a.m. with the administrator and the alternate administrator/supervising nurse, the administrator said LVN K was no longer employed by the agency. The administrator said he would look to see if the agency had a phone number for LVN K. During an interview conducted on 10/13/22 at 9:35 a.m., the alternate administrator/supervising nurse said the agency did not have a phone number for LVN K. During an interview conducted on 10/13/22 at 10:09 a.m. – 10:19 a.m., with LVN I, when asked regarding his skilled nurse visit notes for the visits with Patient #15 documented above which did not indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus to include an assessment of the patient’s blood glucose level during those visits, LVN I said he thought he did recall that the patient would check his own blood glucose levels at times. LVN I said he did not recall ever checking the patient’s blood glucose level himself. LVN I said most of the time the orders on the plan of care are only to check the blood glucose level when the patient is displaying signs and symptoms of hyperglycemia or hypoglycemia or at the patient’s request. LVN I said he did ask the patient during every visit what his blood glucose level was. LVN I said if the patient was showing signs and symptoms of hypoglycemia or hyperglycemia, he would check the blood glucose level and document it. LVN I said he did not recall if Patient #15 kept a blood glucose log in his home. LVN I said the patient did have a privately paid caregiver who checked the blood glucose level. LVN I said he would document that the patient reported the blood glucose level in the section of the skilled nurse’s note designated for information regarding the blood glucose level. LVN I said it was possible he missed documenting this at times. LVN I said he probably did not document that he assessed the blood glucose level if it was not documented in this section of the skilled nurse’s note. LVN I said the agency’s policy and procedure was to document the blood glucose level if the plan of care said to check the blood glucose level and to document if the patient had signs and symptoms of hypoglycemia or hyperglycemia. During an interview conducted on 10/13/22 at 10:37 a.m. – 11:05 a.m., with the administrator and the alternate administrator/supervising nurse, when asked about the agency’s policy and procedure regarding what should be documented to indicate the skilled nurse completed an assessment of a patient with a diagnosis of Type 2 diabetes mellitus, the administrator said the agency’s policy and procedure has been only to document if the agency has an order specifically to check the blood glucose level. The administrator said in the past the agency has been cited for vital signs being out of parameters established on the plan of care, so they have chosen not to document the blood glucose level unless there is a specific order on the plan of care to check the blood glucose level to reduce problems related to this issue. When asked if they would agree that assessment of the blood glucose level would be considered a necessary part of an assessment of a patient with a diagnosis of Type 2 diabetes mellitus, the alternate administrator/supervising nurse said, yes. The alternate administrator/supervising nurse said there could be potential harm to patients related to the skilled nurse failing to document that the blood glucose level had been assessed in that the agency could miss evidence of an exacerbation of a patient’s disease process. The alternate administrator/supervising nurse said she agreed it was fair to say the clinical record would not be complete which could impede the agency’s ability to monitor the patient for concerns related to the diagnosis of Type 2 diabetes mellitus and to report to the physician if the blood glucose level was out of the parameters established on the plan of care. Record review of the agency’s policy titled, “Medical Record Content,” dated 02/01/19, indicated, “Purpose to ensure each medical record … contains complete information which identifies the patient/client, describes problems and needs of the patient/client, justifies patient/client care, and accurately describes care provided, results, significant events and continuity among disciplines … Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) issuing orders for the home health plan of care, and appropriate Agency staff … Each medical record will contain the following … The patient’s/client’s needs information, including the current comprehensive assessment, and all of the assessments from the most recent home health admission and other information which reflect (sic) The patient/client history … Physical assessment/review of systems … Documentation of care provided … Clinical notes documenting all actions, interventions, and procedures provided by the Agency, including medication administration, treatments, and services, and responses to those interventions …”

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure each clinical record included all interventions, including treatments and services, for 2 of 8 (Patient #3 and Patient #7) patients reviewed with physician orders for the skilled nurse to provide wound care to the patient. This failure resulted in the patients’ clinical records being incomplete and could result in harm to patients related to a lack of effective communication. The findings included: Record review of the clinical record for Patient #3 included a plan of care, for the certification period of 08/28/22 – 10/26/22, which indicated the patient had diagnoses of cutaneous abscess of left lower limb and cellulitis of left lower limb. The plan of care indicated the patient was to receive skilled nursing visits twice a week for four weeks. Record review of the clinical record for Patient #3 included a physician’s order, dated 08/31/22, which indicated, “… Skilled Nurse to perform/instruct Patient/Caregiver wound care to Wound #1 Left upper thigh posterior infection wound … cleanse with normal saline and gauze, pat dry, apply skin protectant to peri wound, border peri wound with KCI transparent drape [a type of transparent wound dressing used with wound vacuum assisted closure devices – a medical device used to assist in wound healing], apply Medihoney to wound bed then fill wound with black foam [a type of absorbent wound dressing used with wound vacuum assisted closure devices] cut to fit wound bed size, cover with KCI transparent drape, cut small opening in center of applied drape at area of wound, position tubing and connector over Therapy Unit, activate KCI V.A.C. Therapy Unit [a type of wound vacuum assisted closure device] @ [at] 125 mmHg continuous 3 x week [three times a week]. Apply Ace wrap [a type of bandage used to wrap wounds or injuries] with every Vac [wound vacuum assisted closure device] change. Effective 09/02/22.” Record review of the clinical record for Patient #3 included a physician’s order, dated 09/07/22, which indicated, “Continue Skilled Nurse to perform/instruct Patient/Caregiver wound care to Wound #1 Left upper thigh posterior infection wound … cleanse with normal saline and gauze, pat dry, apply skin protectant to peri wound, border peri wound with KCI transparent drape, apply Medihoney to wound bed then fill wound with black foam cut to fit wound bed size, cover with KCI transparent drape, cut small opening in center of applied drape at area of wound, position tubing and connector over Therapy Unit, activate KCI V.A.C. Therapy Unit @ 125 mmHg continuous 3 x week. Apply Ace wrap with every Vac change. Effective 09/07/22.” Record review of the clinical record for Patient #3 included a physician’s order, dated 09/14/22, which indicated, “Continue Skilled Nurse to perform/instruct Patient/Caregiver wound care to Wound #1 Left upper thigh posterior infection wound … cleanse with normal saline and gauze, pat dry, apply skin protectant to peri wound, border peri wound with KCI transparent drape, apply Medihoney to wound bed then fill wound with black foam cut to fit wound bed size, cover with KCI transparent drape, cut small opening in center of applied drape at area of wound, position tubing and connector over Therapy Unit, activate KCI V.A.C. Therapy Unit @ 125 mmHg continuous 3 x week. Apply Ace wrap with every Vac change. Effective 09/14/22.” Record review of the clinical record for Patient #3 included skilled nurse’s notes, dated 09/02/22, 09/09/22, 09/12/22, and 09/16/22, signed by LVN D, which did not include documentation to indicate the skilled nurse provided the intervention/treatment of application of Medihoney to Patient #3’s Wound #1 during these visits. Record review of the clinical record for Patient #3 included a skilled nurse’s note, dated 09/05/22, signed by LVN E, which did not include documentation to indicate the skilled nurse provided the intervention/treatment of application of Medihoney to Patient #3’s Wound #1 during this visit. During an interview conducted on 10/11/22 at 10:16 a.m. – 10:31 a.m., LVN D reviewed her skilled nurse’s notes for the visits with Patient #3 and said on 09/02/22, 09/09/22, 09/12/22, and 09/16/22 she did apply the Medihoney to Wound #1 and just forgot to document this. LVN D said she would normally document all steps taken to perform the wound care when providing the wound care. LVN D said it was the agency’s policy and procedure for the nurse to document all steps provided as part of the wound care performed. LVN D said she didn’t know why she had failed to document that she had applied the Medihoney during these visits. During an interview conducted on 10/11/22 at 10:55 a.m. – 11:01 a.m., LVN E said on 09/05/22 she did recall Patient #3 had Medihoney in her home but as she was reviewing her skilled nurse’s note for this visit, she didn’t see that she had documented that she had applied the Medihoney to Wound #1 during this visit. LVN E said she believed that she had applied the Medihoney to Wound #1 during this visit and had just forgotten to document it. LVN E said it was the agency’s policy and procedure for the nurse to document exactly what wound care had been provided on each skilled nurse’s visit note. LVN E said normally she would document each step she took when providing the wound care. Record review of the clinical record for Patient #7 included a plan of care, for the certification period of 08/26/22 – 10/24/22, which indicated the patient had a diagnosis of a cutaneous abscess to the back. The plan of care indicated the patient was to receive skilled nurse visits once a day for fourteen days. Record review of the clinical record for Patient #7 included a physician’s order, dated 08/30/22, which indicated, “… Skilled Nurse to perform/instruct patient/caregiver wound care to Wound #1 Left center back infection wound … cleanse with hydrogen peroxide [a type of cleansing solution used to treat or prevent infection] and cotton-tipped applicator, pat dry, apply mupirocin [a topical medication used to treat or prevent infection] to wound bed, lightly pack with Hydrofera blue tunneling dressing [a type of wound dressing used to treat or prevent infection] moistened with N/S [normal saline], cover with gauze and secure with tape three times weekly. Effective 08/30/22.” Record review of the clinical record for Patient #7 included a skilled nurse’s note, dated 09/01/22, signed by LVN D, which indicated, “Skilled nurse performed/instructed patient on wound care to Wound #1 Left center back infection wound … SN cleansed with hydrogen peroxide and cotton-tipped applicator, patted dry with gauze, applied a thin layer of mupirocin, covered with gauze, secured with tape …” There was no documentation to indicate the skilled nurse provided the intervention/treatment of lightly packing Patient #7’s Wound #1 with Hydrofera blue tunneling dressing during this visit. During an interview conducted on 10/12/22 at 10:58 a.m. – 11:15 a.m., LVN D said on 09/01/22 she did apply the Hydrofera blue to Patient #7’s Wound #1 and just forgot to document that she did so. LVN D said the agency’s policy and procedure is to document each step of the wound care provided. During an interview conducted on 10/11/22 at 12:03 – 12:30 p.m., the administrator and the alternate administrator/supervising nurse said the skilled nurse should document each step of the wound care provided per the agency’s policy and procedure. When asked if there was any actual or potential harm related to the skilled nurse’s failure to accurately document the wound care provided, the alternate administrator/supervising nurse said there was actual harm related to a lack of communication. Record review of the agency’s policy titled, “Medical Record Content,” dated 02/01/19, indicated, “Purpose to ensure each medical record … contains complete information which identifies the patient/client, describes problems and needs of the patient/client, justifies patient/client care, and accurately describes care provided, results, significant events and continuity among disciplines … Information contained in the clinical record must be accurate, adhere to current clinical record documentation standards of practice, and be available to the physician(s) issuing orders for the home health plan of care, and appropriate Agency staff … Each medical record will contain the following … Documentation of care provided … Clinical notes documenting all actions, interventions, and procedures provided by the Agency, including medication administration, treatments, and services, and responses to those interventions …”