Every finding on record at Golden Care Home Health, LLC

A recertification survey entrance conference was conducted on 03/03/25. The agency was in compliance with no deficiencies cited. Census: Licensed and Certified- 78 Licensed Home Health- 0

A recertification survey entrance conference was conducted on 03/03/25. Census: Licensed and Certified- 78 Licensed Home Health- 0 Acronyms: RN- Registered Nurse LVN- Licensed Vocational Nurse POC- Plan of Care SOC- Start of Care OASIS- Outcome and Assessment Information Set SN-Skilled Nurse Mg- milligrams AV- arteriovenous 24/7- 24 hours a day, 7 days a week IV- intravenous QA- quality assurance

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s status which included all active health and medical problems for 1 of 7 patient records reviewed. (Patient #1) Patient #1's SOC OASIS/comprehensive assessment did not include type, location, or assessment of the dialysis access site. This failure prevented the agency from developing a plan of care that would address all active health and medical concerns for Patient #1. Findings included: Record review of Patient #1’s POC dated 11/12/24 to 01/10/25 indicated a SOC date of 11/12/24, and indicated he was 85 years old with diagnoses including diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), hypertensive heart disease with heart failure (heart can't pump blood well enough to meet your body's needs), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), anxiety disorder (excessive and persistent worry, fear, and nervousness), and history of falling. The POC indicated Patient #1 was ordered skilled nursing visits 1 time a week for 9 weeks, physical therapy 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, then 2 times a week for 2 weeks, and home health aide 1 time a week for 1 week then 2 times a week for 8 weeks. The POC indicated SN to perform complete physical assessment each visit with emphasis on hypertension (high blood pressure) with chronic kidney disease (loss of function in the kidneys). Record review of a RN Oasis SOC assessment for Patient #1 dated 11/12/24 by the RN Alternate Administrator indicated a diagnosis including dependance on renal dialysis. Review of the assessment indicated hemodialysis with dialysis treatment schedule on Monday, Wednesday, and Friday. Further review indicated patient had end stage kidney failure and required dialysis three times a week for filtration. The assessment did not include the type, location, or assessment of the dialysis access site. During an interview on 03/04/25 at 8:59 a.m., Patient #1 said he had been on dialysis for 1 year. He said he only had the left upper arm access site and had that access site the whole time. During an interview on 03/04/25 at 1:18 p.m., the RN Administrator/Supervising Nurse said the time frame for clinicians to turn in documentation following a visit was 7 days from the day they saw the patient. She said reports were ran every Monday to see who was behind. She said the 7 days were for the initial note/visit and did not include going through QA. During an interview on 03/04/25 at 1:30 p.m., the RN Administrator/Supervising Nurse said the location of the dialysis access site, type of access, and education including no blood pressures in that arm should be included in the OASIS assessment. She said a QA nurse audited all 485/POCs, notes, and everything submitted with a signature. During an interview on 03/04/25 at 1:38 p.m., the RN Administrator/Supervising Nurse said a RN did the comprehensive assessments and included the location of the dialysis access site. She said there was a place to put the dialysis site on the assessment. She said comprehensive assessments were audited by a QA nurse. The RN Administrator/Supervising Nurse said the RN Alternate Administrator was aware she missed the shunt for Patient #1 on the assessment. She said assessments were completed at least every 7 days. She said the SN assessed the dialysis site and it was part of the routine assessment every visit. She said there was a place in the SN note to document the assessment of the site including location. She said there was no reason why it wouldn’t be documented on. The RN Administrator/Supervising Nurse said by not documenting or not assessing, it could cause damage to the site and the patient may not be able to get dialysis if the site was messed up. She said also the SN would not know if the site was infected. The RN Administrator/Supervising Nurse said there was a section under integumentary (skin) where the SN could put in the comment box IV access/shunt. She said the SN should have been documenting the access site there. During an interview on 03/04/25 at 1:52 p.m., RN E said location of the dialysis access site was on the 485/POC and OASIS. He said the SN assessed dialysis sites every visit and documented the assessment under the hematological (blood) in the SN visit/assessment. During an interview on 03/04/25 at 1:57 p.m., the RN Alternate Administrator said her, RN E, another RN, and sometimes the RN Administrator completed OASIS assessments. She said the location of the dialysis shunt should be documented on the OASIS and she was aware that she didn’t document on Patient #1’s access site, but she thought she did. During an interview on 03/04/25 at 2:02 p.m., the RN Alternate Administrator said assessments for a dialysis patient included ensuring blood pressure and heart rate were within normal limits, assessing weights, looking at the access site and listening to it. She said the SN was required to assess the site every SN visit. She said Patient #1’s dialysis site was accessed by dialysis 3 times a week, so the SN needed to look at it to make sure he didn’t have problems. She said the SN documented the assessments of the site in the narrative and under integumentary (skin) and explained the assessment in the narrative. She said there was no reason for the site not to be assessed or documented. The RN Alternate Administrator said the timeframe to submit assessments was 7 days. She said if the SNs were not assessing/documenting on the dialysis site it could lead to poor communication with the physician for the status of the site and could cause poor care for the patient overall. She said if an on-call nurse went, they wouldn’t know the patient had an access site if there was no documentation. Record review of a signed RN Job Description by the RN Alternate Administrator dated 09/28/21 indicated “…Coordinate total patient care by conducting comprehensive health and psychosocial evaluation… conduct an initial, and ongoing, comprehensive assessment of the patient’s needs, including OASIS assessments… conduct a physical examination of the patient, including… physical assessment…” Record review of a Comprehensive Assessment Requirements policy dated 2021 indicated “…3. The comprehensive assessment must address, at least, the following items… c… iii. Identification of additional health problems, or pertinent health history… ix. Head-to-toe assessment… xiii. Other needed information that could impact the level of services required to meet the patient, and family, needs…” Record review of a Patient Record Contents policy dated 2021 indicated “…There is a patient record for each induvial who receives care/service that contains all required documentation… Contents of Clinical Record: The record must include documentation of all care/service provided, which includes, but not limited to: 1. Comprehensive assessment… b. all the assessments from the most recent Home Health admission, clinical notes…” Record review of a Collection, Reporting, and Transmission of OASIS Data policy dated 2021 indicated “…1. The encoded OASIS data accurately reflects the patient’s status at the time of assessment…” Record review of a Nursing Services 24/7 policy dated 2021 indicated “…3. Professional Nursing (Registered Nurse) Functions… i. Initial, and ongoing assessments of the client’s needs, including OASIS assessments…”

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the POC contained the required elements to cover all safety measures to protect against injury, amd patient specific interventions and education for 2 of 7 patient records reviewed for plans of care. (Patient #1 & #5) 1. Patient #1’s POC did not include the type or location of the hemodialysis access site (needle or catheter is inserted to allow for the removal and return of blood during dialysis treatment), safety measures, or care interventions for the protection of the dialysis access site. 2. Patient #5’s POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or SN while taking Eliquis (blood thinner). This failure could result in Patient #1 not receiving proper care/instruction to the dialysis access site and could place clients at risk of not recognizing symptoms of bleeding, and not receiving proper care/instruction leading to complications and hospitalization. Findings included: #1: Record review of a RN Oasis Recertification assessment for Patient #1 dated 01/08/25 by the RN Alternate Administrator indicated a diagnosis including dependance on renal dialysis. The assessment indicated hemodialysis (a treatment to clean your blood when your kidneys are not able to) with dialysis treatment schedule on Monday, Wednesday, and Friday. Further review indicated patient had IV shunt/access in left upper arm. Record review of Patient #1’s POC dated 01/11/25 to 03/11/25 indicated a SOC date of 11/12/24, and indicated he was 85 years old with diagnoses including diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), hypertensive heart disease with heart failure (heart can't pump blood well enough to meet your body's needs), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), anxiety disorder (excessive and persistent worry, fear, and nervousness), and history of falling. The POC indicated Patient #1 was ordered skilled nursing visits 1 time a week for 9 weeks, physical therapy 2 times a week for 4 weeks, and home health aide 2 times a week for 8 weeks then 1 time a week for 1 week. The POC did not include the type/location of dialysis access site, safety measures or care interventions of the access site, or patient teaching for the protection of the dialysis access site. During an interview on 03/04/25 at 8:59 a.m., Patient #1 said he had been on dialysis for 1 year. He said he only had the left upper arm access site and had that access site the whole time. #2: Record review of Patient #5’s POC dated 02/05/25 to 04/02/25 indicated a SOC date of 12/15/22, and indicated he was 86 years old with diagnoses including Alzheimer’s disease (gradually destroys memory, thinking skills, and the ability to carry out daily activities), atrial fibrillation (irregular heartbeat), primary hypertension (high blood pressure), chronic pain (persistent), history of falling, long term use of anticoagulants (blood thinners), presence of cardiac pacemaker (electronic device implanted in the chest to regulate the heart's rhythm and rate). The POC indicated Patient #5 was ordered skilled nursing visits 1 time a week for 9 weeks, and home health aide 2 times a week for 8 weeks then 1 time a week for 1 week. The POC medication list indicated Patient #5 took Eliquis (blood thinner) 5mg, one tablet by mouth daily and Clopidogrel Bisulfate (antiplatelet blood-thinning medicine) 75mg, one tablet by mouth once daily. The POC did not include bleeding safety precautions or teaching on signs and symptoms to report to the physician or SN. During an interview on 03/04/25 at 9:35 a.m., LVN C said a 485/POC for a patient on dialysis should include to watch their weight. She said the location of the access site was charted on the flow sheet but was not on the POC. She said the POC should include monitoring the access site, making sure no signs and symptoms of infection, and assess for swelling. LVN C said a 485/POC for a patient on blood thinners included monitor for signs of bleeding, and precautions to take to keep from having injuries. During an interview on 03/04/25 at 10:10 a.m., LVN F said a 485/POC for a patient on dialysis with a shunt/access should include bleeding precautions and blood pressure precautions. LVN F said the SN did not take blood pressures in the arm with the access site. She said for Eliquis/blood thinners the 485/POC should include bleeding precautions, risk for bruising, low blood pressure precautions, black stools (feces), and teaching/reporting signs and symptoms of bleeding. During an interview on 03/04/25 at 1:30 p.m., the RN Administrator/Supervising Nurse said the 485/POC was developed by the electronic system and was built in the OASIS by the RN who completed the OASIS. She said the electronic system built the 485 by what was answered in the OASIS. She said the location of the dialysis access site, type of access, and education including no blood pressures in that arm should be included in the OASIS and on the 485. She said a patient on a blood thinner, there were bleeding precautions and education in the OASIS. The RN Administrator/Supervising Nurse said the LVNs looked at the 485/POC for patient care. She said there was an option on the OASIS for bleeding precautions and should go under safety. She said bleeding precautions should be on the 485/POC. The RN Administrator/Supervising Nurse said when the RN clicked on bleeding precautions under safety it pulled over to the 485/POC. She verified Patient #5’s POC did not have bleeding precautions. The RN Administrator/Supervising Nurse said by the 485/POC not having bleeding precautions the patient could have bleeding gums, blood in stool, and it could cause damage to their health. She said if a patient fell and had a skin tear, they would not know when to report. She said a QA nurse audited all 485/POCs, notes, and everything submitted with a signature, and should have caught it. During an interview on 03/04/25 at 1:38 p.m., the RN Administrator/Supervising Nurse said for a patient on dialysis if the access site and precautions were not on the 485/POC it could damage the patient’s shunt, or the SN would not know it was working correctly. She said the 485/POC were updated every 60 days and developed and updated by the RN. During an interview on 03/04/25 at 1:52 p.m., RN E said a 485/POC for a patient on Eliquis/blood thinner included educating and enforcing bleeding precautions. RN E said he completed Patient #5’s OASIS and put bleeding precautions on the OASIS and 485/POC, he believed. He said a patient on dialysis the 485/POC should include checking weights, check bruit (whooshing or blowing sound) and thrill (vibration) at the dialysis site and making sure the patient was not experiencing complications from dialysis. He said the location of the access site was on the 485 and OASIS. During an interview on 03/04/25 at 1:57 p.m., the RN Alternate Administrator said the 485/POC should include the dialysis access location so the SN can look and know where it was, and that the patient had one. She said safety precautions should include monitor redness to prevent infection due to the patient was immunocompromised (weakened immune system). She said the SN should listen to the flow and palpate (feel) to ensure the access was working properly. She said by not putting the location or safety precautions for the dialysis site on the 485/POC it could cause poor blood flow, blood clot, and lots of things that could cause the patient to go to the emergency room. During an interview on 03/04/25 at 2:02 p.m., the RN Alternate Administrator said the 485/POC was updated every 60 days by the RN. She said the 485/POC for a patient on Eliquis (blood thinner) should include bleeding precautions, so the patient knew what to look for and what to do/what not to do. She said if bleeding precautions were not on the 485/POC the patient wouldn’t know what to look for if the SN was not teaching on going to the hospital if the patient was bleeding out, excessive bruising, and if the patient had a skin tear, they might not know to hold pressure. Record review of a signed RN Job Description by the RN Alternate Administrator dated 09/28/21 indicated “…Develop, and implement, the nursing care plan… Provides skilled nursing care as outlined in the nursing care plan… Teaching, supervising, and counseling the patient, and caregivers, regarding the nursing care needs and other related problems of the patient, at home…” Record review of a signed RN Job Description by RN E dated 12/13/24 indicated “…Develop, and implement, the nursing care plan… Provides skilled nursing care as outlined in the nursing care plan… Teaching, supervising, and counseling the patient, and caregivers, regarding the nursing care needs and other related problems of the patient, at home…” Record review of a Plan of Care Requirements policy dated 2021 indicated “…Plan of Care: Each patient must receive the Home Health services that are written in an individualized plan of care… that identifies the care, and services necessary to meet the patient-specific needs… 3. The individualized plan of care must include the following… k. safety measures to protect against injury… n. patient specific interventions, and education…” Record review of a Patient Assessments/Plan of Care policy dated 2021 indicated “…5. The plan of care should be appropriate for the type of care that is needed… Responsibility of agency: 1. The care plan must specify the care, and services, necessary to meet the patient-specific needs, as identified in the comprehensive assessment…” Record review of a Nursing Services 24/7 policy dated 2021 indicated “…3. Professional Nursing (Registered Nurse) Functions… ii. Initiating the plan of care and revising it, as necessary… iv. Counseling, and educating, the client, and family, regarding the disease process, and self-care techniques, and prevention strategies…” Review of Hemodialysis Catheters: How to Keep Yours Working Well undated and accessed on 03/05/25 at https://www.kidney.org/kidney-topics/hemodialysis-catheters-how-to-keep-yours-working-well indicated “Hemodialysis is a treatment used when your kidneys fail and can no longer clean your blood and remove extra fluid from your body… By taking good care of your access, it will last longer and you will prevent problems such as infection and clotting. Here are some important steps to take: Keep the catheter dressing clean and dry… Never remove the cap on the end of your catheter. Air must not enter the catheter… You can shower or bathe if you have a clear dressing that sticks to your catheter site and the skin around it…. You should avoid letting the catheter or catheter site go under water during a bath. This would increase the chance of moisture getting near the catheter site, which can cause infection…. If the area around your catheter feels sore or looks red, call your dialysis care team at once… The signs and symptoms of a catheter infection include: Fever, chills, drainage from the catheter exit site, redness or tenderness around the catheter exit site, general feeling of weakness and illness…” Review of Eliquis instructions dated 07/25/24 and accessed at https://www.drugs.com/eliquis.html on 03/05/25 indicated “...Eliquis is used to lower the risk of stroke or a blood clot… Eliquis increases your risk of severe or fatal bleeding, especially if you take certain medicines at the same time (including some over-the-counter medicines)… Call your doctor at once if you have signs of bleeding such as: swelling, pain, feeling very weak or dizzy, bleeding gums, nosebleeds, heavy menstrual periods or abnormal vaginal bleeding, blood in your urine, bloody or tarry stools, coughing up blood or vomit that looks like coffee grounds, or any bleeding that will not stop. Eliquis should be stopped 24-48 hours prior to any surgery, invasive procedure, or dental work. Tell your surgeon if you are taking Eliquis… Do not stop taking Eliquis unless your doctor tells you to. Stopping suddenly can increase your risk of blood clot or stroke…”

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 record review and interview, the agency failed to maintain clinical records to ensure that care and services were completely and accurately documented for 1 of 7 patients whose clinical record was reviewed. (Patient #1) Patient #1’s subsequent health assessments did not include type, location, or assessment of the dialysis access site. This failure could result in infection or complications of Patient #1’s dialysis access site and could lead to hospitalization. Findings included: Record review of Patient #1’s POC dated 11/12/24 to 01/10/25 indicated a SOC date of 11/12/24, and indicated he was 85 years old with diagnoses including diabetes mellitus (body either doesn't produce enough insulin, or it resists insulin), hypertensive heart disease with heart failure (heart can't pump blood well enough to meet your body's needs), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), chronic obstructive pulmonary disease (lung disease causing restricted airflow and breathing problems), anxiety disorder (excessive and persistent worry, fear, and nervousness), and history of falling. The POC indicated Patient #1 was ordered skilled nursing visits 1 time a week for 9 weeks, physical therapy 1 time a week for 1 week, 2 times a week for 1 week, 1 time a week for 1 week, then 2 times a week for 2 weeks, and home health aide 1 time a week for 1 week then 2 times a week for 8 weeks. The POC indicated SN to perform complete physical assessment each visit with emphasis on hypertension (high blood pressure) with chronic kidney disease (loss of function in the kidneys). Record review of Patient #1’s POC dated 01/11/25 to 03/11/25 indicated a SOC date of 11/12/24, and indicated he was 85 years old with diagnoses including diabetes mellitus, hypertensive heart disease with heart failure, end stage renal disease, dependence on renal dialysis, chronic obstructive pulmonary disease, anxiety disorder, and history of falling. The POC indicated Patient #1 was ordered skilled nursing visits 1 time a week for 9 weeks, physical therapy 2 times a week for 4 weeks, and home health aide 2 times a week for 8 weeks then 1 time a week for 1 week. The POC indicated SN to perform complete physical assessment each visit with emphasis on diabetes mellitus with chronic kidney disease. Record review of SN Visit notes/assessments for Patient #1 dated 11/20/24, 11/27/24, 12/04/24, 12/11/24, 12/18/24, 12/23/24, 12/31/24, 01/15/25, 01/22/25, 01/29/25, 02/05/25, 02/12/25, and 02/19/25 by LVN C indicated hemodialysis with dialysis treatment on Monday, Wednesday, and Friday. The narratives indicated patient had end stage kidney failure and required dialysis three times a week for filtration. The visit notes/assessments did not include the type, location, or assessment of the dialysis access site. During an interview on 03/04/25 at 8:59 a.m., Patient #1 said he had been on dialysis for 1 year. He said he only had the left upper arm access site and had that access site the whole time. During an interview on 03/04/25 at 9:35 a.m., LVN C said the SN had 7 days to submit assessments/notes. She said every visit the SN assessed the dialysis site and documented the assessment in the narrative. She said she always assessed Patient #1’s site and documented it in the flowsheet. During an interview on 03/04/25 at 10:10 a.m., LVN F said the SN had 7 days to turn in assessments/notes after a visit. She said for a patient with a dialysis access site, the SN assessed the site every time/visit. She said the assessment was documented in the notes each visit. During an interview on 03/04/25 at 1:18 p.m., the RN Administrator/Supervising Nurse said the time frame for clinicians to turn in documentation following a visit was 7 days from the day they saw the patient. She said reports were ran every Monday to see who was behind. She said the 7 days were for the initial note/visit and did not include going through QA. During an interview on 03/04/25 at 1:30 p.m., the RN Administrator/Supervising Nurse said the location of the dialysis access site, type of access, and education including no blood pressures in that arm should be included in the OASIS assessment. She said a QA nurse audited all 485/POCs, notes, and everything submitted with a signature. During an interview on 03/04/25 at 1:38 p.m., the RN Administrator/Supervising Nurse said a RN did the comprehensive assessments and included the location of the dialysis access site. She said there was a place to put the dialysis site on the assessment. She said comprehensive assessments were audited by a QA nurse. She said assessments were completed at least every 7 days. She said the SN assessed the dialysis site and it was part of the routine assessment every visit. She said there was a place in the SN note to document the assessment of the site including location. She said there was no reason why it wouldn’t be documented on. The RN Administrator/Supervising Nurse said by not documenting or not assessing, it could cause damage to the site and the patient may not be able to get dialysis if the site was messed up. She said also the SN would not know if the site was infected. The RN Administrator/Supervising Nurse said LVN C looked in the notes and didn’t find anywhere she documented on Patient #1’s dialysis site. She said LVN C thought she documented on the access site. The RN Administrator/Supervising Nurse said there was a section under integumentary (skin) where the SN could put in the comment box IV access/shunt. She said the SN should have been documenting the access site there. During an interview on 03/04/25 at 1:52 p.m., RN E said location of the dialysis access site was on the 485/POC and OASIS. He said the SN assessed dialysis sites every visit and documented the assessment under the hematological (blood) in the SN visit/assessment. During an interview on 03/04/25 at 2:02 p.m., the RN Alternate Administrator said assessments for a dialysis patient included ensuring blood pressure and heart rate were within normal limits, assessing weights, looking at the access site and listening to it. She said the SN was required to assess the site every SN visit. She said Patient #1’s dialysis site was accessed by dialysis 3 times a week, so the SN needed to look at it to make sure he didn’t have problems. She said the SN documented the assessments of the site in the narrative and under integumentary (skin) and explained the assessment in the narrative. She said there was no reason for the site not to be assessed or documented. The RN Alternate Administrator said the timeframe to submit assessments was 7 days. She said if the SNs were not assessing/documenting on the dialysis site it could lead to poor communication with the physician for the status of the site and could cause poor care for the patient overall. She said if an on-call nurse went, they wouldn’t know the patient had an access site if there was no documentation. Record review of a signed LVN Job Description by LVN C and dated 04/13/23 indicated “…Provide skilled nursing care… Assist with the preparation, implementation, and continuing evaluation of the patient care plan… prepare clinical and progress notes…” Record review of a Skilled Professional Services policy dated 2021 indicated “…Patient records must show evidence that skilled professionals assume responsibility for, but not restricted to, the following: 1. Ongoing interdisciplinary assessment of the patient…6. Preparing clinical notes…” Record review of a Patient Record Contents policy dated 2021 indicated “…There is a patient record for each induvial who receives care/service that contains all required documentation… Contents of Clinical Record: The record must include documentation of all care/service provided, which includes, but not limited to: 1… b. all the assessments from the most recent Home Health admission, clinical notes…” Record review of a Nursing Services 24/7 policy dated 2021 indicated “…4. Licensed Practical Nurse/Licensed Vocational Nurse Functions… i. Providing services, in accordance with agency policies. ii. Preparing clinical, and progress, notes… iv. Assisting the RN in carrying out the plan of care…”