Every finding on record at Bayada Home Health Care, Inc.

An onsite recertification survey was conducted 2/12/24-2/13/24. No deficiencies to the Emergency Preparedness Program were identified.

An onsite recertification survey was conducted 2/12/24-2/14/24. Deficiencies to the Medicare Conditions of Participation were identified.

Accuracy of encoded OASIS data CFR(s): 484.45(b) Standard: The encoded OASIS data must accurately reflect the patient's status at the time of assessment. This STANDARD is not met as evidenced by: Based on agency policy, clinical record review and staff interviews, the agency failed to ensure accuracy of the OASIS [Outcome and Assessment Information Set-a group of standard date elements included in comprehensive assessments] for 4 of 17 patients [ #1, 4, 7 and 17]. The findings included: 1. Patient # 1 had a Start of Care [SOC] date of 8/17/23 with an admitting diagnosis of Marfan Syndrome [multi-systemic genetic disorder that affects the connective tissue]. Review of the Plan of Care for the certification period 8/17/23- 10/15/23 revealed the patient was ordered Aspirin 81 mg daily and Oxycodone 5 mg every 4 hours as needed for pain and Warfarin [blood thinner] 3 mg daily. Review of the clinical record revealed PT [physical therapy] # 4 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 8/17/23. Further review of the clinical record revealed the PT failed to capture the pain medication when answering N0415 [high risk medications] on the OASIS.]. During an interview with PT # 4 on 2/13/24 at approximately 3 pm, the PT confirmed N0415 was incorrect. 2. Patient # 4 had a Start of Care [SOC] date of 10/6/23 and an admitting diagnosis of sepsis [infection in the blood] due to methicillin susceptible staphylococcus aureus [type of bacteria]. Review of the Plan of Care [POC] for the certification period 10/6/23-2/4/23 revealed the patient was ordered Aspirin 81 mg each day and Zyvox [antibiotic] 2 times per day. Review of the clinical record revealed RN # 8 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 10/6/23. Further review of the clinical record revealed the RN failed to capture the antibiotic when answering N0415 [high risk medications] on the OASIS. RN # 8 was not available for an interview. During an interview with the agency director on 2/13/24 at approximately 3:15 pm, the director confirmed the OASIS was not accurate. 3. Patient # 7 had a Start of Care [SOC] date of 1/5/24 with an admitting diagnosis of hemiplegia [paralysis on one side of the body] following cerebral infarction [stroke] affecting the non-dominant side. Review of the Plan of Care for the certification period 1/5/24-3/4/24 revealed Aspirin 81 mg daily and Metformin [used for diabetes] 500 mg two times a day was ordered by the physician. Review of the clinical record revealed PT [physical therapy] # 4 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 1/5/24. Further review of the clinical record revealed PT # 4 failed to include aspirin as an antiplatelet [prevents blood from clotting] when answering the OASIS question N0415 [high risk medications]. During an interview with PT # 4 on 2/13/24 at approximately 3 pm, the PT confirmed N0415 was incorrect. 4. Patient # 17 had a Start of Care [SOC] date of 1/29/24 with an admitting diagnosis of respiratory syncytial virus [RSV] pneumonia [lung infection]. Review of the clinical record revealed RN # 5 completed the SOC OASIS [The Outcome and Assessment Information Set-patient specific, standardized assessment] on 1/29/24. Further review of the clinical record revealed RN # 5 did not capture Toujeo Max U-300 Solostar 300 units per ml insulin pen [medication used to treat diabetes] when she answered NO415 [question related to use of high-risk medication]. During an interview with RN # 5 on 2/13/24 at approximation 2:45 pm, the RN stated, “I guess I just missed that.”

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: G574 Based on agency policy review, clinical record review and patient/staff interviews the Plan of Care [POC] failed to include all current medications the patient was using for 4 of 7 home visits observed (#12,11,13 & 17) The findings included: 2. Patient # 11 had a Start of Care [SOC] date of 1/22/24 with an admitting diagnosis of essential hypertension. Review of the Plan of Care [POC] for the certification period 1/22/24-3/21/24 included orders for OT [occupational therapy] 1 time a week for 4 weeks. On 2/12/24 at approximately 11 am a joint visit was conducted with OT # 7. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed NicoDerm [patch used to help stop smoking] CQ 21 mg/24 hr. Apply 1 patch daily. During an interview with the patient during the visit, she stated, “I have never used that. I told them when they asked me at the hospital.” During an interview with OT # 7, he confirmed the POC was inaccurate for medications. 3. Patient # 13 had a Start of Care [SOC] date of 1/17/24 with an admitting diagnosis of unspecified dementia with other behavioral disturbances. Review of the Plan of Care [POC] for the certification period 1/17/24-3/16/24 included orders for SN [skilled nursing] 1 time a week for 7 weeks and “…continuous review of medication regimen…” On 2/13/24 at approximately 10 am a joint home visit was made with RN # 5. During the visit a medication review was conducted using the medication profile provided by the agency. The following discrepancies were noted: The medication profile listed Omeprazole [reflux medication] 40 mg each day. During an interview with the caregiver, the caregiver reported the patient only takes 20 mg of Omeprazole. The daughter stated, “She has only taken 20 mg for several months now.” The caregiver presented a bottle of Fish Oil [supplement] 1000 mg and stated the patient was taking this “for several years now”. The Fish Oil was not included on the POC. The caregiver also reported the patient was taking Iron [supplement] 324 mg every other day. During the interview, the caregiver stated the patient had been on Iron since her last hospitalization which was prior to the admission to home health. During an interview with RN # 5 on 2/13/24 at approximately 3 pm, the RN confirmed the POC did not include all the correct medications the patient was taking. 4. Patient # 17 had a Start of Care [SOC] date of 1/29/24 with an admitting diagnosis of respiratory syncytial virus [RSV] pneumonia [lung infection]. Review of the Plan of Care [POC] for the certification period 1/29/24 to 3/28/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks and “continuous review of medication regimen…”. On 2/13/24 at approximately 1:30 pm a joint visit was conducted with LPN # 6. During the visit a medication review was conducted using a medication profile provided by the agency. The following discrepancy was noted: The medication profile listed Vitamin D2 [supplement] 1250 mcg 1 tablet weekly. During an interview with the patient on 2/13/24, the patient stated, “I have never taken any Vitamin D.” During an interview with LPN # 6 the LPN confirmed the POC was not accurate. The policy, “Client Plan of Care”, revised 07/05/21 was provided by the agency director on 02/13/24 at 3:58 p.m. The policy stated, "...the client plan of care includes all medications and treatments…activities permitted”. 1.Patient #12 was admitted on 01/30/24 with diagnoses of encounter for surgical aftercare following circulatory surgery, other ventricular tachycardia (fast heart rate), and essential hypertension. The Plan of Care (POC) for 01/30/24-03/29/24 included orders for physical therapy 1 time a week for 4 weeks, and occupational therapy 1 time a week for 1 week. A home visit was conducted with the physical therapist on 02/12/24 at 2:45 p.m. A medication review was conducted and revealed the following discrepancy: -sodium chloride (saline nasal spray) 1 spray into both nostrils as needed for nasal congestion was not included on the plan of care. Interview with the patient on 02/12/24 at 3:00 p.m. revealed the patient has been using the nose spray since 01/23/24.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the Registered Nurse failed to document a wound assessment in the clinical record for 1 of 5 patients with a wound [#17]. The findings included: Patient # 17 had a Start of Care [SOC] date of 1/29/24 with an admitting diagnosis of respiratory syncytial virus [RSV] pneumonia [lung infection] and other mechanical complication of internal fixation of bones of foot and toes. Review of the Plan of Care [POC] for the certification period 1/29/24 to 3/28/24 included orders for SN [skilled nursing] 1 time a week for 5 weeks. Review of the clinical record revealed RN # 5 completed the SOC comprehensive assessment on 1/29/24. RN # 5 documented the following, “…The patient has a device in his R [right] toe. The device is protruding through the skin. The patient will have surgical repair in February…” Further review of RN # 5’s documentation revealed no wound assessment related to the right great toe. LPN # 6 conducted a routine visit on 2/6/24. Review of the clinical record revealed no documentation related to the right great toe for the visit conducted on 2/6/24. During an interview with the agency director on 2/13/24 at approximately 3 pm, the director confirmed a wound assessment should have been documented the patient’s chart.

An onsite recertification survey was conducted 11/15/21-11/17/21. No deficiencies to the Emergency Preparedness Plan was identified.

An onsite recertification/follow up survey was conducted 11/15/21 to 11/17/21. Standard level deficiencies to the Medicare CoP were identified.

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 agency policy, clinical record review and staff interviews the agency failed to update the Plan of Car [POC] with correct/current medications for 1 of 5 discharged charts [#16]. The findings included: The policy, Medications-Reconciliation [no date], was provided by the agency director on 11/16/21. The policy stated,"...3. In home care, a complete medication reconciliation should be preformed:...b. When the patient has been transferred to another setting and has returned to home care..." Patient # 16 had a Start of Care [SOC] date of 5/17/2021 and an admitting diagnosis of Opioid Depend with Opioid Induced Psychotic Disorder with Hallucinations. A review of the Plan of Care [POC] for the certification period 5/17/21 to 7/15/21 included orders for SN [skilled nursing] 1 time a week for 4 weeks. A review of the clinical record revealed Patient # 16 was seen in the emergency department at _______[name of hospital] on 6/19/21. A review of the medication list dated 6/19/21-6/20/21 from _____[name of the hospital] revealed the following medication changes: Wellbutrin XL 300 mg [patient to stop taking] and Estrace 0.1 mg [patient to stop using]. A review of the medication profile provided by the agency revealed Wellbutrin and Estrace were listed as current medications [not discontinued by RN # 6 ]. An interview was conducted with the agency director on 11/17/21. During the interview the agency director confirmed the medication profile was not updated by RN # 6.

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 on agency policy, clinical record review and staff interviews the agency failed to follow the Plan of Care related to wound care for 1 of 11 patients with a wound [#9]; failed to report blood pressure readings outside the given parameters for 1 of 5 discharged charts [#14]. The findings included: The policy, Client Care Plan [July 5, 2021], was provided by the agency director on 11/16/21. The policy stated, "...The client plan of care includes...All medications and treatments..." 1. Patient # 9 had a Start of Care [SOC] date of 9/26/21 and admitting diagnoses of Hemiplegia, unspecified affecting Left Nondominant side and Pressure Ulcer of Left Buttock, unstageable. A review of the Plan of Care [POC] for the certification period 9/26/21 to 11/24/21 revealed orders for SN 2 times a week for 2 weeks; 1 time a week for 1 week and “skilled nursing…to perform wound care and instruct caregiver to perform wound care to the unstageable pressure ulcer on the left buttock as follows: cleanse with normal saline, apply santyl to the wound bed and cover with bordered foam using clean technique. Change daily and PRN…” A review of the clinical record revealed The SOC visit was completed by RN # 12. Further review of the clinical record revealed the following documentation by RN # 12, “Wound care not provided…” RN # 12 was not available for an interview. The agency director was interviewed on 11/17/21. During the interview the agency director confirmed the RN did not follow the POC related to wound care. A review of the clinical record revealed LPN # 7 made a routine visit on 10/1/21 and documented the following information, “…Patient has not got [sic] santyl. Sn cleaned wound and covered with foam dressing.” A phone interview was conducted with LPN # 7 on 11/17/21. During the interview the LPN confirmed he did not follow the POC related to wound care. 2. Patient # 14 had a Start of Care [SOC] date of 7/16/20 and admitting diagnoses of Multiple fracture of Ribs, Left side, subs for fracture with Routine Healing and Delirium due to Known Physiological Condition. A review of the Plan of Care [POC] for the certification 7/46/20 to 9/13/20 revealed orders for SN [skilled nursing] 1 time a week for 5 weeks, OT [occupational therapy] 1 time a week for 8 weeks and “Licensed professional to report vital signs falling outside the following established parameters…blood pressure systolic less than 95 or greater than 140 and diastolic blood pressure less than 89…” A review of the clinical record revealed the following blood pressure readings: 7/16/20 - 170/95, 7/22/20 - 150/95, 7/31/20 – 150/95, 8/5/20 – 174/95, 8/5/20- 150/95, 8/14/20- 160/95. An interview was conducted with the agency director on 11/17/21. During the interview the director confirmed there was no evidence the blood pressures were reported to the physician in accordance with the POC.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to obtain a physician's order prior to advising a patient with heart failure to increase fluid intake for 1 of 1 patient [#15]. The findings included: Patient # 15 had a Start of Care [SOC] date of 10/28/21 and admitting diagnoses of Hypertensive Heart Disease with Heart Failure and Acute on Chronic Diastolic [Congestive] Heart Failure. A review of the Plan of Care [POC] for the certification period 10/28/21 to 12/26/21 revealed orders for PT [physical therapy] 1 time a week for 1 week; 2 times a week for 1 week; 1 time a week for 5 weeks; 1 time every 2 weeks for 2 weeks. A review of the clinical record revealed PT # 9 made a routine visit on 11/15/21. Further review of the clinical record revealed PT # 9 documented the following information, “Client awake upon PT arrival to her bedroom. She reports not feeling well and having a headache. Client encouraged to drink more water/fluids…Client bp [blood pressure] 108/60 [within parameters]and she was advised to drink more fluids to aid in maintaining BP…Private aide arrived during visit and was asked to encouragement [sic] client to drink more fluids…” Further review of the clinical record revealed no physician's order related to encouraging more water since patient had a diagnosis of congestive heart failure. An interview was conducted with the agency director on 11/17/21. During the interview the director confirmed the staff member should have obtained an order to increase fluids.

Communication with all physicians CFR(s): 484.60(d)(1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review and staff interviews the agency failed to inform the physician of the presence of unremoved staples in 1 of 1 chart with a new colostomy [#2]; failed to notify the physician of a new wound in 2 of 5 discharged charts [#16 and 18]. The findings included: 1. Patient # 2 had a Start of Care [SOC] date of 10/27/21 and admitting diagnoses of Encounter for adjustment and management of VAD [vascular access device], Type 2 Diabetes Mellitus with other Specified Complications and Encounter for Attention to Colostomy. A review of the Plan of Care [POC] for the certification period 10/27/21 to 12/25/21 revealed orders for SN [Skilled nursing] 3 times a week for 1 week; 2 times a week for 2 weeks; 1 time a week for 6 weeks. A review of the SOC OASIS [Outcome and Assessment Information Set] completed by RN # 6 revealed a staple was noted under the colostomy site. A phone interview was conducted with RN # 6 on 11/17/21 at approximately 10 am. During the interview the RN stated, “I tried to tell the doctor about the staple. I called and left a message but never got a call back.” An interview was conducted with the agency director on 11/17/21. During the interview the agency director confirmed the RN should have continued to attempt to call the MD until she received a call back. 2. Patient # 16 had a Start of Care [SOC] date of 5/17/2021 and an admitting diagnosis of Opioid Depend with Opioid Induced Psychotic Disorder with Hallucinations. A review of the Plan of Care [POC] for the certification period 5/17/21 to 7/15/21 included orders for SN [skilled nursing] 1 time a week for 4 weeks. A review of the clinical record revealed RN # 6 made a routine visit on 6/2/21. Further review of the clinical record revealed the following documentations by RN # 6, “…Patient has a stage one on coccyx, patient and caregiver educated on pressure reduction measures and frequent turning and repositioning…RN to notify physician for change in skin integrity…” There is no evidence the physician was notified related to the new skin breakdown. During an interview with the RN on 11/17/21 the RN stated, “I called the md office at least every week and I am sure I told him. I guess I didn’t chart it.” 3. Patient # 18 had a Start of Care [SOC] date of 5/15/21 and admitting diagnoses of Paroxysmal Atrial Fibrillation and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. A review of the Plan of Care [POC] for the certification period 5/15/21 to 7/13/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 1 time a week for 6 weeks. A supplemental order was written on 6/6/21 with a visit frequency for the SN of 3 times a week for 1 week; 4 times a week for 1 week; 2 times a week for 4 weeks. A review of the clinical record revealed RN # 12 made a routine visit on 7/3/21 and documented the following information, “…Buttocks assessed due to caregiver calling to report new ulcers are on her bottom. She has 2 small pressure ulcers stage 2 one on each buttock…” Further review of the clinical record revealed no evidence the physician was notified of the new wounds. RN # 12 was not available for an interview. An interview was conducted with the agency director on 11/17/21. During the interview the agency director confirmed the physician was not notified of the new wound.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on policy review, client record review, and staff interview the clinical record failed to include weekly wound assessments/measurements for wound measurements for 8 of 11 charts with wounds [#5, 9, 12, 14, 16, 18, 1 and 17];failed to include PICC [peripherally inserted central catheter] line measurements for 1 of 1 patient with a PICC line [#2]. The findings included: The policy, Wound Care-Assessment and Treatment [September 9, 2021] was provided by the agency director on 11/17/21. The policy stated, "...Wound should be measured in centimeters once per week and/or as per physician order..." Review of a policy “0-3230 Wound Care – Assessment and Treatment,” revised 09/09/21 was received from the agency director on 11/17/21 at 9:00 a.m. The policy stated, “… wounds should be measured in centimeters weekly…”. 7. Patient #1 was admitted on 10/05/21 with diagnoses of encounter for orthopedic aftercare, type 3 diabetes, osteomyelitis (bone infection) of right ankle and foot, history of diabetic foot ulcer. Skilled nursing orders were 2 times a week for 6 weeks, and 1 time a week for 1 week. Orders for skilled nursing to perform wound care to bilateral lower feet. Cleanse all wounds with wound cleanser, apply hydrofera blue to wound bed and cover and secure with roll gauze and tape using aseptic technique. Change dressing 2 times a week and prn (as needed) for soilage/dislodgement. Review of skilled nursing notes for dates of 10/20/21, 10/22/21, 10/25/21, 10/29/21, 11/01/21, 11/05/21, 11/08/21, and 11/12/21 revealed measurements were not obtained for the weeks of 10/20/21 and 11/08/21 skilled nurse visits. Interview with Employee #1 on 11/17/21 at 9:02 a.m. “I charted the nursing visit, I did the wound care, I just didn’t complete the wound addendum, …“I don’t measure wounds, the RN measures wounds”. Interview with Employee #5 11/17/21 at 9:43 a.m. “ I would have to look at my know , it could be an error on my part-clinician error for not documenting the wound care or the measurements.” 8. Patient #17 was admitted was admitted on 02/06/21 with diagnoses of type 2 diabetes, urinary incontinence, essential hypertension, and unstageable ulcer to right heel. Skilled nursing orders were 1 time a week for 5 weeks, 1 time every 2 weeks for 2 weeks, and 4 times every 2 weeks 2. Orders for skilled nurse to paint heel with betadine daily, cleanse with soap and water dry well, skin preop wound and periwound apply silver alginate to wound bed and cover with foam dressing. Review of skilled nursing notes for dates of 02/06/21, 02/11/21, 02/17/21, 02/24/21, 03/02/21, 03/05/21, 03/08/21, 03/10/21, 03/15/21, 03/18/21, 03/22/21, 03/25/21, and 04/01/21 revealed measurements were not obtained for the week of 03/08/21. Interview with agency director on 11/17/21 at 11:02 a.m. revealed, ” no registered nurse visit this week, so wound was not measured. Employee #13 no longer works for the agency. 1. Patient # 5 had a Start of Care [SOC] date of 8/2/21. A review of the Plan of Care for the certification period 10/1/21 to 11/29/21 revealed diagnoses of Encounter for Change or Removal of Surgical Wound Dressing, Type 2 Diabetes Mellitus with Other Specified Complication and other Acute Osteomyelitis, Left ankle, and foot. A review of the POC revealed orders for SN [Skilled nursing] 1 time a week for 1 week; 3 times a week for 8 weeks; 1 time a week for 1 week and “skilled nurse to apply negative pressure wound therapy pump. Cleanse wound to left foot…change dressing 3 times per week…” A review of the clinical record revealed SN visit were made on 10/25/21, 10/27/21 and 10/29/21. Further review of the clinical record revealed no wound measurements for the week of 10/25/21. An interview was conducted with the agency director on 11/17/21. During the interview the director confirmed no measurements were documented for the week of 10/25/21. 2. Patient # 9 had a Start of Care [SOC] date of 9/26/21 and admitting diagnoses of Hemiplegia, unspecified affecting Left Nondominant side and Pressure Ulcer of Left Buttock, unstageable. A review of the Plan of Care [POC] for the certification period 9/26/21 to 11/24/21 revealed orders for SN 2 times a week for 2 weeks; 1 time a week for 1 week and “skilled nursing…to perform wound care and instruct caregiver to perform wound care to the unstageable pressure ulcer on the left buttock as follows: cleanse with normal saline, apply santyl to the wound bed and cover with bordered foam using clean technique. Change daily and PRN…” A review of the clinical record revealed no documented wound measurements from 9/26/21 until the visit on 10/13/21. An interview was conducted with the agency director on 11/17/21. During the interview the agency director confirmed the wound should have measurements documented weekly. 3. Patient # 12 had a Start of Care [SOC] date of 11/3/21 and admitting diagnoses of Type 2 Diabetes Mellitus with Foot Ulcer and Non-Prs [pressure] Chronic Ulcer of Right Heel and Midfoot. A review of the certification period 11/3/21 to 1/1/2022 revealed orders for SN [skilled nursing] 1 time a week for 1 week with a supplemental order for SN 2 times a week for 6 weeks and “Skilled nursing…to perform wound are and instruct caregiver/patient to perform wound care. Perform wound care to right ankle. Cleanse with wound cleanser, apply alginate to wound bed and cover…Secure with foam dressing …change dressing 2 times per week and prn…” A review of the clinical record revealed LPN # 1 made a routine visit on 11/12/21. Further review of the clinical record revealed no wound assessment for that visit. A phone interview was conducted with LPN # 1 on 11/17/21. During the interview the LPN stated, “I did the assessment and the wound care. I guess I just failed to attach the wound addendum.” 4. Patient # 14 had a Start of Care [SOC] date of 7/16/20 and admitting diagnoses of Multiple fracture of Ribs, Left side, subs for fracture with Routine Healing and Delirium due to Known Physiological Condition. A review of the Plan of Care [POC] for the certification 7/46/20 to 9/13/20 revealed orders for SN [skilled nursing] 1 time a week for 5 weeks. A review of the clinical record revealed RN # 6 saw the patient on 7/22/20, 7/29/20, 8/5/20 for routine visits. Further review of the clinical record revealed no wound assessment/measurements for the wound until 8/27/21. An interview was conducted with the agency director on 11/17/21. During the interview the director confirmed the clinical record did not include the wound assessment/measurements. 5. Patient # 16 had a Start of Care [SOC] date of 5/17/2021 and an admitting diagnosis of Opioid Depend with Opioid Induced Psychotic Disorder with Hallucinations. A review of the Plan of Care [POC] for the certification period 5/17/21 to 7/15/21 included orders for SN [skilled nursing] 1 time a week for 4 weeks. A review of the clinical record revealed RN # 6 made a routine visit on 6/2/21. Further review of the clinical record revealed the following documentations by RN # 6, “…Patient has a stage one on coccyx, patient and caregiver educated on pressure reduction measures and frequent turning and repositioning.” The wound assessment revealed no wound measurements. An interview was conducted with RN # 6 on 11/17/21. During the interview the RN stated, “I guess I didn’t enter the measurements.” 6. Patient # 18 had a Start of Care [SOC] date of 5/15/21 and admitting diagnoses of Paroxysmal Atrial Fibrillation and Hypertensive Heart and Chronic Kidney Disease with Heart Failure. A review of the Plan of Care [POC] for the certification period 5/15/21 to 7/13/21 revealed orders for SN [skilled nursing] 1 time a week for 1 week; 3 times a week for 1 week; 2 times a week for 1 week; 1 time a week for 6 weeks. A supplemental order was written on 6/6/21 with a visit frequency for the SN of 3 times a week for 1 week; 4 times a week for 1 week; 2 times a week for 4 weeks. A review of the clinical record revealed LPN # 13 made a routine visit on 6/23/21. Further review of the clinical record revealed the following documentation by LPN # 13 on 6/23/21, “…Pressure ulcer to sacral area found. Reported to RN…” Further review of the clinical record revealed no documented wound assessment/measurements. LPN # 13 was not available for interview. The agency director was interviewed on 11/17/21. During the interview the director confirmed the clinical record did not include a wound assessment/measurement for the sacral wound identified on 6/23/21. RN # 12 made a routine visit on 7/3/21 and documented the following information, “…Buttocks assessed due to caregiver calling to report new ulcers are on her bottom. She has 2 small pressure ulcers stage 2 one on each buttock…” Further review of the clinical record revealed no documented wound assessment or wound measurements. RN # 12 was not available for interview. During the interview with the agency director on 11/17/21 she confirmed there was no wound assessment or wound measurements in the clinical record. RN # 4 saw Patient # 18 on 7/7/21 for a discharge visit. A review of the clinical record revealed RN # 4 documented the patient had 2 stage II pressure ulcers at the time of discharge. Further review of the clinical record revealed no evidence of a wound assessment or wound measurements. An interview was conducted with RN # 4 on 11/17/21. RN # 4 confirmed the clinical record did not include a wound assessment or wound measurements. The policy, Infusion Therapy-Central Line Type-PICC [no date], was provided by the agency director on 11/17/21. The policy stated, "...Dressing change...Document...c. Length of catheter external and effective internal lengths..." 1. Patient # 2 had a Start of Care [SOC] date of 10/27/21 and admitting diagnoses of Encounter for adjustment and management of VAD [vascular access device] and Type 2 Diabetes Mellitus with other Specified Complications. A review of the Plan of Care [POC] for the certification period 10/27/21 to 12/25/21 revealed orders for SN [Skilled nursing] 3 times a week for 1 week; 2 times a week for 2 weeks; 1 time a week for 6 weeks and “…Perform IV site care using sterile technique…” A review of the clinical record revealed on admission the PICC [peripherally inserted central catheter] line measurements were recorded as 0 cm exposed catheter from insertion site to hub of catheter and an arm circumference of 29 cm. Further review of the clinical record revealed the PICC line dressing was changed on 11/1/21 and 11/8/21 by LPN # 1. Further review of the clinical record revealed no PICC line measurements on those dates. A phone interview was conducted with LPN # 1 on 11/17/21 at 9 am. During the interview the LPN confirmed she did not obtain PICC line measurements. An interview was conducted with the agency director on 11/16/21 at approximately 2 pm. During the interview the agency director confirmed PICC line measurements should have been documented with each dressing change.