Every finding on record at Glovis Home Health Services Inc

• Purpose of visit: Recertification/Relicensure/Complaint • Entrance date: 12/09/2024 • Census: L&CHHS 20 LHHS 36 PAS 120 • Intake#: 380656; 387265; 438988; 493341 The facility is in compliance with no deficiencies cited.

• Purpose of visit: Recertification/Relicensure/Complaint • Entrance date: 12/09/2024 • Census: L&CHHS 20 LHHS 36 PAS 120 • Intake#: 380656; 387265; 438988; 493341 Abbreviations: Licensed Home Health Services (LHHS) Personal Assistance Services (PAS) Licensed and Certified Home Health Services (L&CHHS) Quality Improvement Organization (QIO) Electronic Medical Record (EMR) Outcome and Assessment Information Set (OASIS) Internet Quality Improvement and Evaluation System (IQIES an internet-based system that includes survey and certification functions) Centers for Medicare & Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC) Advance Beneficiary Notice (ABN) Plan of Care (POC) Registered Nurse (RN) As Needed (PRN)

Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to electronically transmit the completed Outcome and Assessment Information Set (OASIS) assessment for 208 of 287 of assessments reviewed to the state agency within 30 days of completing the OASIS assessment of the patient. Failure of the agency to transmit OASIS data within the required time frame prevented the agency’s patient data from being made available to Centers for Medicare & Medicaid Services (CMS) for analysis to identify agency performance levels in the provision of patient care. Findings: The surveyor reviewed the OASIS transmission report for the agency on the Internet Quality Improvement and Evaluation System (IQIES an internet-based system that includes survey and certification functions) portal on 12/06/2024, as part of the preparation for the survey. The Home Health Agency Error Summary by Agency report revealed 208 assessments were submitted late over a 12-month period out of 287 assessments submitted. In an interview with the Administrator on 12/10/2024 at approximately 10:26 AM, the surveyor requested the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report for the last 12 months and asked who was responsible for the Oasis transmissions. The Administrator said, “Me and the Alternate Administrator/Director of Nursing are responsible for the Oasis transmissions.” The surveyor reviewed the OASIS Agency Final Validation reports provided by the Administrator on 12/11/2024. The agency Oasis Agency Final Validation report documented: The report documented the date of the Admission Assessment as entered by the agency at OASIS assessment item M0090 (Oasis coding used to determine the last date that information used to complete the assessment completed) was submitted more than 30 days after the M0090 date for 37 different patients. The report documented the following error message: “Record submitted late: The submission date is more than 30 days after M0090 on this new record.” An interview was conducted with the Administrator on 12/11/2024 at 2:50 PM. The surveyor reviewed the Centers for Medicare & Medicaid Services (CMS) OASIS Agency Final Validation report provided the agency with the Office Manager and Alternate Administrator/Director of Nursing. The surveyor reviewed the findings of the late transmission of the assessments. The surveyor asked why the Oasis were transmitted late by the agency. The Administrator stated, “It was an oversight. Medicare contacted the agency about the errors. Our payments from Medicare will be reduced because of the errors. We are working on correcting the errors.”

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: THIS IS A CONTINUED DEFICIENCY PREVIOUSLY CITED AT G0442 ON SURVEY DATED 12/15/2021. Based on record review and interview, the agency failed to provide a proper written notice in advance of terminating on-going care in two of two discharged patient records (Patient 9 and 10) reviewed. This failure prevented the Patients from exercising their right to dispute the termination of Medicare-covered services. Findings include: A list of discharged patients was provided by the Administrator on 12/12/2024. The list provided the dates and reason for discharge, including those patients that were discharged with their goals met. Review of the discharged list: Discharged Patient #9: revealed a discharge date 02/12/2024 with discharge reason "Lack of Funds". Discharged Patient #10: revealed a discharge date 01/08/2024 with discharge reason "Goals Met". Review of discharge records: Discharged Patient #9 Record review of the electronic medical record (EMR) included a plan of care dated 12/15/2023-02/12/2014. The record contained a discharge Outcome and Assessment Information Set (OASIS) visit on 01/12/2024. The record failed to reveal a discharge notice. Discharged Patient #10 Record review of the electronic medical record (EMR) included a plan of care dated 11/13/2023-01/11/2014. The record contained a discharge Outcome and Assessment Information Set (OASIS) visit on 01/08/2024. The record failed to reveal a discharge notice. During an interview with the Administrator on 12/12/2024 at approximately 10:40 AM the surveyor presented the above findings. The surveyor requested the discharge notices. The administrator stated the notices were kept in a binder and thought the notices were uploaded into the EMR. The administrator provided the discharge notices for patients #9 and #10. Review of discharge notices: Review of the discharge notice revealed a Center for Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage" was signed and dated by Patient #9 on 01/23/2024. The form included the incorrect Quality Improvement Organization (QIO), Identifier AA phone contact number XXX-XXX-4227. Patient #9 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), Identifier CC phone contact number XXX-XXX-0636. Review of the discharge notice revealed a Center for Medicare/ Medicaid Services (CMS) form titled, "Notice of Medicare Non-Coverage" was signed and dated by Patient #10 on 01/01/2024. The form included the incorrect Quality Improvement Organization (QIO), Identifier BB phone contact number XXX-XXX-5442. Patient #9 should have received the notice of appeal that included the correct Quality Improvement Organization (QIO), Identifier CC phone contact number XXX-XXX-0636. During an interview with the Administrator on 12/12/2024 at approximately 11:14 AM the surveyor presented the above findings. The surveyor asked the Administrator, why the discharged patients had not been given the correct contact phone number of the Quality Improvement Organization (QIO) for the patients to appeal the discharge decision prior to when home health services ended. The surveyor and the Administrator reviewed the agency's Medicare QIO form provided to the discharged patients. The surveyor the Administrator discussed the incorrect phone numbers and the phone number for the QIO. The Administrator stated she was not aware the QIO contact phone number was incorrect. Review of agency policy dated 050124, quoted in part, “Billing Process/Advance Beneficiary Notice/False Claims RI.50…Notice of Medicare Non-Coverage (NOMNC) A. When all Medicare covered home health care is terminated, the Agency may be required to deliver the Notice of Medicare Non-Coverage (NOMNC) (see the Discharge Notices Policy). B. The NOMNC informs the patient/client, or representative, of the right to an expedited determination by a Quality Improvement Organization (QIO) if it is believed that termination of home health services is not appropriate. C. If the QIO decides that Medicare covered care should end and the patient/client, or representative, wishes to continue receiving care from the Agency even though Medicare will not pay, an ABN must be issued to the patient/client since this would be an initiation of noncovered care…” Review of agency policy dated 050224, quoted in part, “Patient/Client Transfer, Discharge, and Agency Dissolution PE.25… II. Discharge… G. The Agency will provide notice to eligible patients/clients of the right to expedited determinations using the Notice of Medicare Non-Coverage (an OMB-approved Medicare form) when the period of covered care ends. I. The Agency will provide the Advance Beneficiary Notice (ABN) according to the procedures in the Billing Process/Advance Beneficiary Notice/False Claims policy.…” Review of agency policy dated 050124, quoted in part, “Patient/Client Transfer and Discharge Notices PE.30… IV. The Agency will deliver a Detailed Explanation of Non-Coverage (an OMB-approved Medicare form) to the patient/client and the appropriate Quality Improvement Organization (QIO) if the patient/client requests an expedited review by the QIO of the decision that coverage for items and/or services should end…”

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to enforce written policies to control infections and communicable diseases that included requirements to document infections that the patient acquires while receiving services from the agency for one of one active patients (Patient #1) receiving antibiotic treatment. This deficient practice places the active patients at risk of receiving inadequate care and services from the agency's inability to monitor and trend infections and antibiotic use while receiving care from the agency. The findings included: Review of Patient #1's medical record revealed Plan of Care signed and dated by Registered Nurse (RN) A and dated 10/17/2024 with a start of care date 10/1/24 for certification period from 10/1/24 through11/29/24 with a principal diagnosis of Type 2 diabetes mellitus with foot ulcer (formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. A diabetic ulcer describes a slow-healing wound that commonly appears on the feet) and a SN frequency of 1 time a week for one week, three times a week for six weeks with three as needed visits (PRN). The plan of care read in part, “SN to perform wound care to Right foot lateral plantar diabetic ulcer…Apply Tetracyte (a topical antibiotic that treats a variety of bacterial infections, including those associated with acne, cuts, scrapes, burns, and chronic wounds) …” Review of the Physician's Order dated 12/5/24 revealed " Apply Tetracyte and medical grade honey to the wound bed. Cover with non-bordered foam dressing 2x weekly and as needed (PRN) for soiled or loose dressing…” Review of the Infection Control Log revealed no documented evidence that a review form was completed for Patient #1. During an interview with Registered Nurse (RN) A on 12/12/2024 at 1:55 PM. The surveyor reviewed the above findings. The surveyor asked was an infection control report documented. Registered Nurse (RN) A stated, “It was an oversight on my part.” During an interview with the Director of Nursing/Alternate Administrator and the Administrator on 12/12/2024 at 2:47 PM, the surveyor reviewed the findings. The Administrator stated, “It’s the agency's policy to document patients that were on antibiotics when they were admitted to the agency.” The Director of Nursing/Alternate Administrator stated, “It was an oversight.” Review of the agency's policy titled "Infection Control Program" dated 050124, revealed "...The Infection Control Program will include…A system that coordinates: .1. Surveillance for the occurrence of an infection 2. Identification of the occurrence 3. Implementing appropriate preventative procedures 4. Implementing appropriate measures to control infection 5. Review of the data collected to evaluate trends, pattern, etc. 6. Reporting the data and any identified trends as appropriate...Documentation completed by all staff will include at a minimum: 1. Date infection was detected 2. Patient’s/patient's name 3. Primary diagnosis 4. Sign/symptoms 5. Type of infection 6. Pathogen identified if any 7. Treatment..."

A Recertification Survey entrance conference was conducted on 12/07/2021 at 12:15 AM with the Adm. Census: LCHHS: 42 LHH: 0 PAS: 100 An exit conference was conducted on 12/15/2021 at 7:35 PM with the Adm and the Alt Adm/DON. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. The agency was found in compliance with 42 CFR Part 484.22 Medicare Conditions of Participation and no deficiencies were cited.

A Recertification Survey and Complaint (ID: 232349) entrance conference was conducted on 12/07/2021 at 12:15 AM with the Adm. Census: LCHHS: 42 LHH: 0 PAS: 100 An exit conference was conducted on 12/15/2021 at 7:35 PM with the Adm and the Alt Adm/DON. 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. Deficiencies cited at standard level. ABBREVIATIONS ABD - abdominal Adm – Administrator Alt – Alternate AM - Ante meridiem BP – Blood Pressure cc - cubic centimeter CFR – Code of Federal Regulations cm - centimeter CMS - Centers for Medicare and Medicaid Services COVID-19 -Novel Coronavirus Disease of 2019 DON - Director of Nurses Dr - doctor emr: electronic medical record Fr - french HF – heart failure HHCCN - Home Health Change of Care Notice LCHHS - Licensed and Certified Home Health LHHS - Licensed Home Health Services lpm – liters per minute LUE – left upper extremity LVN -Licensed Vocational Nurse Mg - milligram M-W-F – Monday, Wednesday, Friday NC – nasal canula No - Number 02 - oxygen OASIS- Outcome and Assessment Information Set OT – occupational therapist PAS- Personal Assistance Services PIP – Personal Improvement Project PM - Post meridiem prn - as needed PT – Physical Therapist PTA- Physical Therapy Assistant POC - plan of care q - every QAPI- Quality Assurance Performance Improvement QIO – Quality Improvement Organization RN - registered nurse SN - skilled nurse SOC – start of care Tab - tablet

Written notice for non-covered care CFR(s): 484.50(c)(8) Receive proper written notice, in advance of a specific service being furnished, if the HHA believes that the service may be non-covered care; or in advance of the HHA reducing or terminating on-going care. The HHA must also comply with the requirements of 42 CFR 405.1200 through 405.1204. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide a completed written Notice of Medicare Non Coverage, FORM No. CMS 10123, no later than two days in advance of terminating on-going care in three of three DC'd patient records (Patient 6, 7 and 8 ) reviewed. The agency failed to provide the CMS form titled "Notice of Medicare Non-Coverage". This failure prevented Patients from exercising the right to appeal the DC decision, if desired. FINDINGS INCLUDE: A patient DC list with DC reason was provided to the surveyor via email by the Alt Adm/DON on 12/09/2021 which included the DC date of 10/20/2021 for Patient 6, 02/03/2021 for Patient 7 and 11/12/2021 for Patient 8. During an interview with the Alt Adm/DON on 12/14/2021 at12:00 PM, the surveyor presented the findings of where DC notices were kept. The Alt Adm/DON stated in a notebook, not in the emr. The Alt Adm/DON gave the surveyor a white notebook and stated all DC notices were included in the notebook. DC'd Patient 6: Record review of the emr included a POC dated 09/11/2021 to 11/09/2021. The record contained an SN DC OASIS visit on 10/20/2021. The notebook contained a form titled, “HOME HEALTH CHANGE OF CARE NOTICE (HHCCN)” Form CMS-10280 that included Patient 6’s name. The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. DC'd Patient 7: Record review of the emr included a POC dated 12/06/2020 to 02/03/2021. The record contained an SN DC OASIS visit on 02/03/2021. The notebook contained a form titled, “HOME HEALTH CHANGE OF CARE NOTICE (HHCCN)” Form CMS-10280 that included Patient 7’s name. The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. DC'd Patient 8: Record review of the emr included a POC dated 09/13/2021 to 11/11/2021. The record contained a SN DC OASIS visit on 11/11/2021. The notebook contained a form titled, “HOME HEALTH CHANGE OF CARE NOTICE (HHCCN)” Form CMS-10280 that included Patient 8’s name. The record did not include a Notice of Medicare Non-Coverage FORM No. CMS 10123. During an interview with the Adm and the Alt Adm/DON on 12/15/2021 at 6:00 PM, the surveyor presented the above findings of why the agency failed to provide a completed written Notice of Medicare Non Coverage no later than two days in advance of terminating on-going care and if the signed forms titled, “HOME HEALTH CHANGE OF CARE NOTICE (HHCCN)” that Patient 6, 7 and 8 signed were the only notices given to the patients prior to DC. The Adm stated, “Yes”, those were the only notices because the agency thought they were providing the correct form. Agency policy titled, "PATIENT/CLIENT TRANSFER AND DC NOTICES PE.6" with a revision date of 08/01/2020 read in part, " ... PURPOSE To provide guidance on completion of the required ...discharge notices... POLICY I. Prior to ...discharging a patient/client, the Agency will provide written notification to the patient/client or the patient's/client's parent, family, spouse, significant other or legal representative…II. The Agency will provide notice to eligible patients/clients of their right to expedited determinations when their period of covered care ends…III. The Agency will deliver the Notice of Medicare Non-Coverage ...to the patient/client (or authorized representative), at least two (2) calendar days before Medicare covered services end ...V. The Agency will provide the Home Health Change of Care Notice (HHCCN) to inform a patient/client…when the Agency is discharging due to Agency reasons, for example, when the Agency is unable to continue to staff the patient/client care or the home is unsafe for staff…C. The Agency will keep the following in the patient's/client's file: 1. A copy of the written notification provided to the patient/client or their parent, family, spouse, significant other, or legal representative ...II. Notice of Medicare Non-Coverage (NOMNC) ... A. Agency staff will provide valid delivery notice (involves both delivery and completion) of the NOMNC to the patient/client (or their representative) when the end of all covered care is foreseen, even if the patient/client agrees with the discharge. B. At least two (2) calendar days before Medicare covered services end...the Agency representative will provide the NOMNC to the patient/client ... I. The Agency will have the patient/client (or their representative) complete and sign the NOMNC. The patient/client or representative should sign and date two copies, keep one, and return a copy to the Agency ..." Regulation: July 1, 2005, the new Medicare regulations, Benefits Improvement and Protection Act gave beneficiaries access to the new expedited determination process when their home health agency services were ending. There were two notices required by these regulations. The first was a generic notice called a Notice of Medicare Provider Non-coverage labeled "FORM No. CMS 10123" that the provider would be delivered at least two days prior to when a beneficiary's Medicare coverage of services was ending. The telephone number for the QIO was to be included in the notice. The second was a detailed notice, called a Detailed Explanation of Provider Non-Coverage that the provider would deliver to the beneficiary and the appropriate QIO only if the beneficiary requested an expedited review by the QIO of the decision that coverage for items and/or services should end.

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 record review and interview, the agency failed to ensure the POC included types of services, supplies and equipment; nutritional requirements; medications and treatments; safety measures; education and training; pertinent activity orders; caregiver status; nutritional requirements; and patient specific interventions and education for 7 of 7 patients (1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Patients 1, 2, 3, 4, 5, 6 and 7 POC’s did not include safety measures for wounds; safety measures for a suprapubic catheter; safety measures for post cerebrovascular disease; bleeding safety measures for a blood thinner medication; a complete medication list; the types of services, supplies and equipment required; patient specific interventions and education; and nutritional requirements and caregiver status. These failures could place the agency's active patients receiving LCHHS services at risk of injury, infection and deteriorating health status. Findings Include: Patient 1: Record review of the emr included a POC dated 09/05/2021 to 11/03/2021 that included a diagnosis of stage 4 pressure ulcer of sacral region (full thickness tissue loss with exposed bone, tendon or muscle as a result of pressure) and diabetes mellitus. The POC included an order for the SN to visit the patient one time a week for nine weeks and one time a week for one week. The POC read in part, “….SN to perform complete physical assessment each visit with emphasis on Pressure Ulcer…stage 4… SN to perform pressure ulcer care to the coccyx, M-W-F, and as needed. Cleanse/irrigate the wound with normal saline solution, blot dry, apply Alginate dressing (a wound dressing used to absorb many times their own weight) to wound bed, cover and secure with a secondary foam dressing (a wound dressing that is absorbent and nonadherent), using aseptic technique… Roho cushion (a pressure relief cushion) for wheelchair…SN to insert size 24fr/10 cc catheter to gravity drainage system q monthly and as needed for occlusion, dislodgement or malfunction of catheter. Using aseptic technique, SN to perform catheter irrigation with normal solution…SN to perform finger stick for blood glucose analysis every visit. SN to prepare/teach patient/caregiver to administer insulin Novolin (an injectable medicine used to lower blood sugar levels)… SN to perform medication review each skilled nursing visit and reconcile medications as indicated…Due to the complexity of care, patient requires skilled intervention for bladder irrigation via suprapubic urinary catheter (a catheter that permits direct urinary drainage from the bladder through the lower abdominal wall)...” The POC did not include safety measures for wounds; a complete medication list to include Novolin insulin; wound care supplies; suprapubic catheter supplies; and diabetic supplies. During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately 3:14 PM, the surveyor presented the above findings of why the POC did not include safety measures for wounds. The Alt Adm/DON reviewed the POC and stated only general information was included on the POC but it was not specific enough. The surveyor presented the above findings of why the POC did not include a complete medication list to include Novolin. The Alt Adm/DON stated the patient was not taking Novolin injections at that time because his blood sugar had been normal. The Alt Adm/DON stated the patient had already stopped taking the medication when the episode started on 09/05/2021. The surveyor presented the findings of why Novolin was included in the POC with instructions for the SN to teach the patient/caregiver to administer if the patient was not taking the medication. The Alt Adm/DON stated it should not have been included on the POC. Patient 2: Record review of the emr included a POC dated 09/25/2021 to 11/23/2021 that included a diagnosis of encounter for change or removal of surgical wound dressing; absence of left great toe; acquired absence of other left toe(s); chronic obstructive pulmonary disease (constriction of the airways and difficulty or discomfort in breathing); HF; and dependence on supplemental O2. The POC included an order for the SN to visit the patient every day for 21 days, two times a week for five weeks and one time a week for one week. The POC included a medication list that read in part, “…Losartan 25 MG oral tablet take ½ tab daily by mouth…Amlodipine 5 MG oral tablet 1 tablet daily by mouth… Oxygen 5 LPM via NC nasal…” The POC read in part, “…SN to perform wound care to left foot, daily. Cleanse wound with normal saline solution, Betadine (a medicine used to prevent and treat skin and wound infections) to the incision and the left 2nd and 3rd toes, then cover incision with 4x4 and Kerlix (a dressing used to cushion and protect wounds) , and a light 4 inch ACE (an elasticized bandage) using aseptic technique…SN to instruct patient/caregiver regarding self- management of oxygen therapy, perform risk assessment and administer O2 at [3.5] liters per minute via NC…SN to perform medication review each skilled nursing visit and reconcile medications as indicated...” The POC did not include appropriate interventions for the SN to assess for HF signs and symptoms with abnormal parameters to report to the physician, wound care supplies, a complete medication list to include Betadine, safety measures for the wound and bleeding safety precautions for the blood thinner medication. According to Healio Cardiology, assessment and interventions of HF includes: weight increase, shortness of breath, pitting edema (swelling due to excessive fluid accumulation in body tissues), abnormal lung sounds, jugular vein distension, ascites (distended or tense abdomen) and physician notification of signs and symptoms. According to the Mayo clinic, safety precautions while taking blood thinners include: Be careful when using a regular toothbrush, dental floss, or toothpick; be careful not to cut yourself when you are using sharp objects, such as a safety razor or fingernail or toenail cutters; avoid contact sports or other situations where bruising or injury could occur; check with your doctor right away if you notice any unusual bleeding or bruising, black, tarry stools, blood in the urine or stools, or pinpoint red spots on your skin. The record included an SN visit note conducted by LVN on 09/26/2021 that read in part, “…SN noticed the patient's first stage pressure ulcer located at the major gluteal muscle (a muscle on the buttocks) by the coccygeal bone (tailbone) on both sides. SN performed perineal (the area extending from the anus to the external genitalia) care and applied aloe Vera and collagen cream on the affected area. Aloe Vera and collagen cream were not included on the POC or medication list. The record included an SN visit note conducted by LVN on 10/07/2021 that read in part, “…SN instructed the patient about the doctors order to hold the Amlodipine medicine (lowers BP) as is prescribed to be hold…” The order to hold Amlodipine was not included on the POC or medication list. The record included a communication note to Patient 2’s physician signed by LVN on 10/07/2021 that read in part, “…SN instructed the patient about the doctors order to hold the Amlodipine medicine as is prescribed to be hold for a diastolic blood pressure less than 60…” The order to hold Amlodipine was not included on the POC or medication list. The record included an SN visit note conducted by LVN on 10/12/2021 that read in part, “…SN called Dr…about the patient's symptoms today and the last Saturday when she hit her arm and opened her skin about 0.3 cm but was bleeding for more than 3 hours, the patient has bruises all over her body and she stated she is bleeding rectally, SN observed her feces, the patient's feces are dark brown ( not red blood was observed (sic))…The patient stopped taking Amlodipine 5 days ago as prescribed to hold it for a diastolic pressure less than 60…SN received the new order to hold Losartan (lowers BP) 12.5 mg until blood pressure aceptable (sic) readings and to hold Clopidogrel (a blood thinner) 75 mg and to keep administrating Aspirin 81 mg until new order from the vascular doctor…” The order to hold Losartan and Clopidogrel was not included on the POC or medication list. Aspirin was not included on the POC or medication list. The POC did not include bleeding safety precautions for the blood thinner medication. The record included a communication note to Patient 2’s physician signed by LVN on 10/12/2021 that read in part, “…The patient stopped taking Amlodipine 5 days ago as prescribed to hold it for a diastolic pressure less than 60 mmHg. SN received the new order to hold Losartan 12.5 mg until blood pressure aceptable (sic) readings and to hold Clopidogrel 75 mg and to keep administrating Aspirin 81 mg until new order from the vascular doctor. …” The note was not signed by the physician. The order to hold Losartan and Clopidogrel was not included on the POC or medication list. Aspirin was not included on the POC or medication list. The POC did not include bleeding safety precautions for the blood thinner medication. The record included an SN visit note conducted by LVN on 10/15/2021 that read in part, “…Current Medication Aspirin/ Clopidrogrel…Patient with excessive bruising, Physician Notified Anticoagulation Complication…” The POC did not include bleeding safety precautions for the blood thinner medication and orders for restarting Clopidogrel. During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately 2:51 PM, the surveyor presented the findings of how agency nurses assess patients for signs and symptoms of HF. The Alt Adm/DON stated the nurses look for edema, weight gain, wheezing in the chest, difficulty breathing and fluid overload. During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately 3:27 PM, the surveyor presented the above findings of why the POC did not include appropriate interventions for the SN to assess for HF signs and symptoms with abnormal parameters to report to the physician. The Alt Adm/DON stated the agency had that information on the POC prior to the patient developing a wound but since the foot wound developed, it was difficult for the patient to step on a scale to weigh; so therefore, the agency assessed the patient for edema. The surveyor presented the above findings of why the POC did not include a complete medication list to include Betadine, Aloe Vera, Collagen Cream, Aspirin and to hold Amlodipine, Losartan and Clopidrogel. The Alt Adm/DON stated Betadine was listed in the body of the POC and asked if it should be added to the medication list as well. Alt Adm/DON stated the agency’s emr system did not allow the agency to enter a one-day medication on the medication profile, they had to enter the medication as either DC’d or continued. The surveyor presented the above findings of why the POC did not include safety measures for the wound and bleeding safety precautions for the blood thinner medication. The Alt Adm/DON stated the POC only included general information regarding a pressure ulcer but nothing specific. The Adm looked at the Alt Adm/DON and asked if the agency was supposed to add an addendum to the POC to add bleeding precautions. The Alt Adm/DON told the Adm yes, that was what they should have done. The surveyor presented the findings of what impact these agency failures could have on the patient. The Alt Adm/DON stated the quality of care provided by the agency offsets any negative outcome. Patient 3: Record review of the emr included a POC dated 06/11/2021 to 10/08/2021 that included a diagnosis of Diabetes, open wound to left knee, hypertension, cerebral aneurysm, cerebral infarction and hemiplegia (total or partial paralysis of one side of the body) affecting the left side. The POC included an order for the SN to visit the patient one time a week for one week, two times a week for three weeks and one time a week for five weeks; PT one time a week for one week effective week of 06/13/2021 and OT one time a week for one week effective week of 06/13/2021. The POC read in part, “…Caregiver Status There is no data for this section…SN to perform wound care to abrasion wound left knee. Cleanse wound with normal solution, apply Alginate dressing, cover with ABD (dressing used for large wounds or for wounds requiring high absorbency) pad cut to size, and secure with tapes (sic), using aseptic technique…SN to perform finger stick for blood glucose analysis every visit… open scabbed wound with moderate purulent (pus) drainage to the left knee from abrasion…” The POC did not include safety measures for wounds; safety measures to ensure no BP’s were taken or blood draws performed on the left arm affected by the Cerebrovascular Disease; a complete medication list; wound care supplies; diabetic supplies; and caregiver status. According to The National Institutes of Health, after a stroke (or cerebrovascular disease), the blood pressure should always be measured in the unaffected arm. The record included a supplemental physician order signed by Alt Adm/DON on 06/11/2021 that included an order for the SN to visit the patient one time a week for one week, two times a week for three weeks and one time a week for five weeks; PT one time a week for one week effective week of 06/13/2021 and OT one time a week for one week effective week of 06/13/2021…” The order did not include safety measures for wounds; safety measures to ensure no BP’s were taken or blood draws performed on the left arm affected by the Cerebrovascular Disease; a complete medication list; wound care supplies; diabetic supplies; the types of services, supplies and equipment required; and caregiver status. The record included a supplemental physician order signed by Alt Adm/DON on 06/11/2021 that read in part, “…SN to perform wound care to abrasion wound left knee. Cleanse wound with normal saline solution, apply Alginate dressing, cover with ABD pad cut to size, and secure with tapes, using aseptic technique twice a week until the wound healed…” The order did not include safety measures for wounds; safety measures to ensure no BP’s were taken or blood draws performed on the left arm affected by the Cerebrovascular Disease; a complete medication list; wound care supplies; diabetic supplies; the types of services, supplies and equipment required; and caregiver status. The record included an PT evaluation visit conducted by PT on 07/16/2021 that read in part, “…Blood Pressure…127/69…LUE…” The BP was taken on the left side affected by hemiplegia. The record included an PTA visit conducted by PTA on 07/22/2021 that read in part, “…Significant clinical findings: Patient has high BP upon arrival…He stated…he is taking a new BP pill…” The new BP pill was not included on the medication list. The record included an SN reassessment visit conducted by Alt Adm/DON on 08/09/2021 that read in part, “…BP Sitting Left: 156/79…” The BP was taken on the left side affected by hemiplegia. During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately 4:50 PM, the surveyor presented the above findings of why the POC did not include safety measures for the wounds and safety measures to ensure no BP’s were taken or blood draws performed on the left arm affected by the Cerebrovascular Disease. The Alt Adm/DON stated it was just an oversight. The surveyor presented the above findings of why the POC did not include a complete medication list. The Adm stated Patient 3 had just been admitted to service by the agency and had previously been homeless; a nurse practitioner conducted a visit on Patient 3 and ordered new medications by calling prescriptions into the pharmacy. The surveyor presented the findings of if the agency nurses reviewed patient medications during visits conducted. The Adm stated, “the patient was supposed to be on hold so the nurse wasn’t making visits at that time.” The surveyor presented the above findings of why the POC did not include caregiver status. The Alt Adm/DON stated the patient had not qualified for attendant services so they were unable to complete that section on the POC. The surveyor presented the findings of what impact these agency failures could have on the patient. The Alt Adm/DON stated the agency provided good care for the patient. Patient 4: Record review of the emr included a POC dated 10/22/2021 to 12/20/2021 that included a diagnosis of Diabetes. The POC included an order for the SN to visit the patient one time a week for one week, two times a week for two weeks and one time a week for six weeks. The POC read in part, “…SN to perform finger stick for blood glucose analysis every visit…” The POC did not include diabetic supplies. The surveyor presented the findings of what impact these agency failures could have on the patient. The Alt Adm/DON stated he didn’t think the patient was impacted. Patient 5: Record review of the emr included a POC dated 08/18/2020 to 10/16/2020 that included a diagnosis of Diabetes. The POC included an order for the SN to visit the patient two times a week for nine weeks. The POC read in part, “…Caregiver Status There is no data for this section…SN to perform finger stick for blood glucose analysis every visit…” The POC did not include diabetic supplies, nutritional requirements and caregiver status. During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately 5:50 PM, the surveyor presented the above findings of why the POC did not include nutritional requirements and caregiver status. Alt Adm/DON stated it was an oversight. The surveyor presented the findings of what impact these agency failures could have on the patient. The Alt Adm/DON stated the quality of care provided by the agency offsets any negative outcome. Patient 6: Record review of the emr included a POC dated 09/11/2021 to 11/09/2021 that included a diagnosis of acute pain due to trauma; displaced fracture of acetabulum (part of the hip joint). The POC included an order for the SN to visit the patient one time a week for nine weeks. The POC read in part, “…SN to perform wound care to leg - right trochanter every other day. Cleanse wound with wound cleanser, pat dry, apply skin prep to…wound, apply two telfa pads (a type of dressing) over the incision, and secure with Medipore tape and as needed…” The order did not include safety measures for wounds and wound care supplies. During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately PM, the surveyor presented the above findings of why the POC did not include safety measures for the wound. The Alt Adm/DON stated there was nothing specific on the POC regarding safety measure for the wound. Patient 7: Record review of the emr included a POC dated 12/06/2020 to 02/03/2021 that included a diagnosis of diabetes. The POC included an order for the SN to visit the patient one time a week for nine weeks. The POC read in part, “…SN to perform finger stick for blood glucose analysis every visit…” The POC did not include diabetic supplies. During an interview with the Alt Adm/DON at 2:40 PM, the surveyor presented the above findings of why the POC’s for Patient 1, 2, 3, 4, 5, 6 and 7 did not include wound care supplies, suprapubic catheter supplies, and/or diabetic supplies. The Alt Adm/DON stated the agency lists supplies for some types of patients including those with a colostomy supplies but a patient’s wound care and supplies can change. The surveyor presented the findings of what impact these agency failures could have on the patient. The Alt Adm/DON stated the agency nurses do wound teaching all the time and if a patient uses a trapeze bar (patient transfer device), they taught positioning every visit. Agency Policy titled, "PLAN OF CARE PC.8" with a revision date of 11/01/2020, read in part, “…PURPOSE To ensure that care provided is appropriately planned…to meet the patient’s/client’s specific needs and problems…POLICY I. The Agency will use data/information gathered during patient/client assessments in the care planning process which involves the identification of patient/client…actions and interventions that will resolve or alleviate the patient’s/client’s problems and/or needs…PROCEDURE I. The appropriate licensed professional staff member…is responsible for developing the plan of care…III. Each patient/client must receive an individualized written plan of care…The individualized plan of care must specify the care and services necessary to meet the patient/client specific-needs…A. The individualized plan of care must include the following…3. The types of services, supplies, and equipment required; 9. Nutritional Requirements; 10. All medications and treatments; 11. Safety measures to protect against injury…14. Patient/client-specific interventions and education…” Agency Policy titled, "ORDERS FOR CARE PC.7" with a revision date of 11/01/2020, read in part, "PURPOSE To ensure patient/client care is provided in accordance with a physician…order and federal and state laws and regulations…POLICY A. The Agency will obtain orders and provide care in accordance with…orders…The order will be signed and dated with the date of receipt by the registered nurse…responsible for furnishing or supervising the ordered services…PROCEDURE…I. All orders are kept current and renewed or updated as appropriate…V. The original order is sent/faxed to the physician…and a copy is retained in the patient’s/client’s medical record…IX. Agency staff will verify upon return of an order that the orders is complete, accurate, signed with the date of the orders…XI. When it is received by the Agency, the signed order replaces the copy in the patient’s /client’s medical record…XIV. Verbal orders must be authenticated and dated by the physician…Physician…signatures are obtained on the Plan of Care and supplemental verbal orders within sixty (60) days…Plans of Care should be signed within 30 days and verbal orders should be signed within 14 calendar days…” Agency Policy titled, "MEDICATION LIST AND MONITORING PC.17" with a revision date of 08/01/2020, read in part, “PURPOSE To outline a process for ongoing medication monitoring. POLICY I. An agency RN will be responsible for coordinating the efforts of monitoring the medication regimen by compiling assessment data through a collaborative effort of all Agency staff involved in the patient’s/client’s care. A medication profile/list will be maintained on all patients/clients. II. Medication monitoring will include appropriate date/information to develop an accurate patient/client medication and a current, complete medication profile. This date will be available to all Agency staff involved in the patient/client care. PROCEDURE I. The agency will maintain a current, accurate list of all prescription and over-the-counter…medication taken by the patient/client (Medication Profile)…Professional clinical staff will update the medication list with any change in the medication regimen…”

Performance improvement projects CFR(s): 484.65(d)(1)(2) Standard: Performance improvement projects. Beginning July 13, 2018 HHAs must conduct performance improvement projects. (1) The number and scope of distinct improvement projects conducted annually must reflect the scope, complexity, and past performance of the HHA's services and operations. (2) The HHA must document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to conduct and document PIP(s) for the calendar years 2019, 2020 and 2021 that reflected the scope, complexity and past performance of the agency's services and operations. The failure could place the agency at risk to not improve and provide quality care and services to the agency's patients. Findings Include: Record review of the agency's QAPI manual did not reveal any reports, reviews or documentation that indicated the agency had conducted PIP(s), per federal regulatory requirements, for the years 2019, 2020 and 2021. The manual did not reveal any reports, reviews or documentation that indicated the agency had a PIP in development or on-going for calendar year 2021. During an interview with the Adm and the Alt Adm/DON on 12/15/2021 at approximately 6:30 PM, the surveyor presented the above findings of what the agency's PIP had been for calendar year 2019, 2020 and 2021. The Alt Adm/DON stated he saw something about PIP’s somewhere in an agency manual but did not know what it was. The surveyor presented the above findings of if the agency had a PIP in development or on-going for calendar year 2021. The Alt Adm/DON stated, “No.” Agency policy titled, "Quality Assurance Performance Improvement Program QAPI.1" with a revision date of 01/13/2018, read in part: " ...Procedure…III…D. Performance improvement projects 1. The number and scope of distinct improvement projects conducted annually will reflect the scope, complexity, and past performance of the Agency's services and operations. 2. The Agency will document the quality improvement projects undertaken, the reasons for conducting these projects, and the measurable progress achieved on these projects ..." Agency policy titled, "Quality Assurance Performance Improvement Program QAPI.5" with a revision date of 01/13/2018, read in part: " ...Policy…II. The Governing Body will determine the number and scope of distinct Performance Improvement Projects (PIP) conducted annually…”

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: Based on record review and interview, the SN’S failed to ensure clinical and progress notes were written as required in ten (Patient 4, 5, 10, 11, 12, 13, 14, 15, 16 and 17) of eleven active records reviewed receiving skilled services. This failure placed the agency patients at risk of not receiving the appropriate care and services. Findings include: Record review of the agency's QAPI manual included 11 documents titled, “QAPI MONITORING PROCESS” signed by the Alt Adm/DON on the following dates: 05/24/2019, 08/16/2019, 11/22/2019, 02/21/2020, 05/22/2020, 08/21/2020, 11/20/2020, 4th quarter 2020, 05/21/2021, 08/21/2021 and 11/26/2021 that read in part, “…Identified problem(s): Non-completion of skilled nursing notes in a timely manner Description of Action Plan: Review of patients charts, 10% of all active and 10% of discharged charts to ensure timely completion of notes…” Patient 4: Record review of the emr included a POC dated 10/22/2021 to 12/20/2021. The POC included an order for the SN to visit the patient one time a week for one week, two times a week for two weeks and one time a week for six weeks and three prn visits for disease exacerbation. The POC included orders for the nurse to perform a finger stick blood sugar check every visit, check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr had SN visits scheduled for 10/28/2021, 11/25/2021 and 12/02/2021. The three visit notes included the visit date, Patient 4’s date of birth and medical record number, and primary and secondary diagnosis. The rest of the three notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The three notes were not signed or dated by the SN. The emr included an SOC OASIS SN visit dated 10/22/2021 that was not signed by the SN. Patient 5: Record review of the emr included a POC dated 08/18/2020 to 10/16/2020. The POC included an order for the SN to visit the client two times a week for nine weeks and three prn visits for disease exacerbation. The POC included an order for the SN to perform finger stick blood sugar check every visit. The POC included orders for the nurse to perform a finger stick blood sugar check every visit, check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr had SN visits scheduled for 09/15/2020 and 09/22/2020. The two visit notes included the visit date, Patient 5’s date of birth and medical record number, and primary and secondary diagnosis. The rest of the two notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The two notes were not signed or dated by the SN. Patient 10: Record review of the emr included a POC dated 11/11/2021 to 01/9/2022. The POC included an order for the SN to visit the client one time a week for nine weeks with three prn visits for disease exacerbation. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr had a SN visit scheduled for 11/24/2021. The visit note included the visit date, Patient 10’s date of birth and medical record number, and primary and secondary diagnosis. The rest of the note was incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The note was not signed or dated by the SN. The emr included a SN visit dated 12/01/2021 that was not signed by the SN. Patient 11: Record review of the emr included a POC dated 10/27/2021 to 12/25/2021. The POC included an order for the SN to visit the client two times a week for one week, three times a week for eight weeks with three prn visits for disease processes/colostomy status. The POC included orders for the SN to perform wound care to the sacrum and to instruct the patient/caregiver on colostomy (surgical formation in which a portion of the large intestine is brought through the abdominal wall to carry feces out of the body) management. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr included SN visits scheduled for 10/29/2021, 11/11/2021, 11/13/2021, 11/16/2021, 11/18/2021, 11/20/2021, 11/23/2021, 11/25/2021, 11/27/2021, 11/30/2021, 12/02/2021 and 12/4/2021. The 12 SN visit notes included the visit date, Patient 11’s date of birth and medical record number and primary and secondary diagnosis. The rest of the twelve notes were incomplete and blank without vital signs or assessment information, wound care, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The twelve notes were not signed or dated by the SN. Patient 12: Record review of the emr included a POC dated 9/28/2021 to 11/26/2021. The POC included an order for the SN to visit the client one time a week for nine weeks with three prn visits for supervision and disease exacerbation. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr included SN visits scheduled for 10/30/2021 (resumption of care reassessment OASIS visit), 11/01/2021, 11/03/2021, 11/05/2021, 11/10/2021, 11/17/2021 and 11/22/2021 (recertification reassessment OASIS visit). The 10/30/2021 resumption of care OASIS visit was incomplete and read in part, “…M1600 Has this patient been treated for a Urinary Tract Infection in the Past 14 days…” The answer was not marked. The section labeled Patient Right, Visit Interventions, Medication Review, Visit Narrative and Rehabilitation Potential were blank and incomplete. The OASIS visit was not signed or dated by the SN. The five regular SN notes included the visit date, Patient 12’s date of birth and medical record number and primary and secondary diagnosis. The rest of the five notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The five notes were not signed or dated by the SN. The 11/22/2021 OASIS visit included the visit date, Patient 12’s date of birth, medical record number and the discipline of the person completing the assessment marked as an RN. The rest of the OASIS assessment was incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The recertification OASIS visit was not signed or dated by the SN. There were no SN notes, missed visit notes, orders or communication notes included in the emr after 11/22/2021. Patient 13: Record review of the emr included a POC dated 10/19/2021 to 12/17/2021. The POC included an order for the SN to visit the client one time a week for nine weeks with three prn visits for disease exacerbation. The POC included orders for the SN to monitor blood sugar levels and teach patient/caregiver to administer insulin. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr included SN visits scheduled for 10/20/2021, 11/19/2021, 11/26/2021 and 12/01/2021. The four regular SN notes included the visit date, Patient 13’s date of birth and medical record number and primary and secondary diagnosis. The rest of the four notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The four notes were not signed or dated by the SN. Patient 14: Record review of the emr included a POC dated 10/23/2021 to 12/21/2021. The POC included an order for the SN to visit the client one time a week for nine weeks with three prn visits for disease exacerbation. The POC included orders for the SN to monitor blood sugar levels every visit. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr included SN visits scheduled for 10/23/2021, 10/27/2021, 11/17/2021, 11/24/2021 and 12/01/2021. The five regular SN notes included the visit date, Patient 14’s date of birth and medical record number and primary and secondary diagnosis. The rest of the five notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The five notes were not signed or dated by the SN. Patient 15: Record review of the emr included a POC dated 10/22/2021 to 12/20/2021. The POC included an order for the SN to visit the patient one time a week for nine weeks with three prn visits for disease exacerbation. The POC included orders for the SN to monitor blood sugar levels every visit. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr included SN visits scheduled for 11/19/2021, 11/26/2021 and 12/03/2021. The three regular SN notes included the visit date, Patient 15’s date of birth and medical record number and primary and secondary diagnosis. The rest of the three notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The three notes were not signed or dated by the SN. Patient 16: Record review of the emr included a POC dated 11/18/2021 to 01/16/2022. The POC included an order for the SN to visit the patient one time a week for nine weeks with three prn visits for disease exacerbation. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr included SN visits scheduled for 11/24/2021 and 12/01/2021. The two regular SN notes included the visit date, Patient 16’s date of birth and medical record number and primary and secondary diagnosis. The rest of the two notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The two notes were not signed or dated by the SN. Patient 17: Record review of the emr included a POC dated 10/16/2021 to 12/14/2021. The POC included an order for the SN to visit the patient one time a week for nine weeks with three prn visits for disease exacerbation. The POC included orders for the SN to monitor blood sugar levels every visit. The POC included orders for the SN to check vital signs, perform a complete physical assessment, skilled teaching/training and perform medication review and reconciliation. The emr included SN visits scheduled for 10/20/2021, 10/27/2021, 11/03/2021, 11/10/2021, 11/17/2021, 11/24/2021 and 12/01/2021. The seven regular SN notes included the visit date, Patient 17’s date of birth and medical record number and primary and secondary diagnosis. The rest of the seven notes were incomplete and blank without vital signs or assessment information, interventions, response to care/progress toward goals, medical necessity for care and visit narrative. The seven notes were not signed or dated by the SN. During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately 2:53 PM, the surveyor presented the above findings of why the SN’S failed to ensure clinical and progress notes were written as required. The Adm stated some of the visits could have been missed SN visits that the SN did not enter into the emr as a missed visit. The surveyor asked what the agency policy was on completion timelines. The DON stated the SN’s had five days to complete an SOC and recertification OASIS visit and regular SN visit notes must be turned in within 14 days from the visit date. The Adm reviewed the emr and stated she was surprised so many were incomplete and not signed because if they show up as green in the emr, that meant they were completed. The Adm stated they were green in the emr so the agency did not know they weren’t signed. The surveyor stated even if the emr was incorrect with the display of colors indicating completion, why wasn’t the documentation completed by the SN’s. The Adm stated the only explanation she had was they all must have been missed visits. The surveyor asked if there would be that many missed visits for nine patients. The Adm stated, “No, they must just be late.” During an interview with the Adm and Alt Adm/DON on 12/15/2021 at approximately 3:00 PM, the surveyor presented the above findings found in the QAPI manual of why the agency did not correct the problem of non-completion of skilled nursing notes in a timely manner that was first identified and documented by the Alt Adm/DON on 05/24/2019. The DON stated the agency had a problem with SN note completion during the COVID-19 pandemic due to nurses having to quarantine if exposed to the virus and some SN’s had quit during the pandemic. The Alt Adm/DON stated the agency was overworked and manpower had been a problem during the pandemic. The surveyor stated the problem was identified on 05/24/2019, prior to the COVID-19 pandemic. The Alt Adm/DON stated the problem started with the pandemic but it had always been a problem that had gotten out of hand during the pandemic. Agency Policy titled, "TIMELINES IM.7" with a revision date of 08/01/2020, read in part, “…PURPOSE To establish timely parameters for all medical record information…PROCEDURE…A Registered Nurse, Physical Therapist, or Speech Therapist will complete the Initial Comprehensive Assessment no later than five (5) calender (sic) days after the start of care (SOC) for all patients/clients in a licensed and certified agency… D. Daily progress notes with correlating time sheets are turned in within a maximum of seven (7) calendar days .E. Recertifications/comprehensive reassessments will be completed no earlier than five (5) days prior to end of the episode and no later than the last day of the episode …IV. All clinical and progress notes will be written the day service is rendered. V. All medical record information will be incorporated into the patient’s/client's medical record within fourteen (14) working days. VI. The Agency's quality/performance improvement activities may monitor effectiveness of the medical records parameters and will reevaluate the parameters if negative trends are identified...”