Every finding on record at Granite Healthcare Inc

A recertification survey was completed on 8/23/23. Three deficiencies were cited.

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 each patient had a complete individualized plan of care (POC). Specifically, the agency failed to ensure the POC included all pertinent diagnosis, supplies and equipment required and all medications and treatments in 4 of 9 patient records reviewed who received skilled nursing (SN) services (Patients #2, #3, #5 and #12). Findings include: AGENCY POLICY According to the agency policy, Care Planning Process, revised May 2022, in part: "The patient-specific clinical plan of care includes: - All pertinent primary and secondary diagnoses; - Orders for patient-specific home health service needs identified in the comprehensive assessment and responsible discipline(s), treatments and procedures, including amount/frequency/duration; - Supplies and Equipment required" 1. The clinical record for Patient #3 was reviewed on 8/21/23. The POC for the certification period dated 5/4/23 to 7/2/23 revealed a start of care date of 3/10/22; diagnosis included venous insufficiency, congestive heart failure, kidney disease, diabetes, anemia, abnormalities of gait and mobility, uropathy, paralytic ileus, metabolic syndrome, cervicalgia, hyperlipidemia, rheumatoid arthritis, history of urinary tract infections, and non-pressure ulcers of right leg. Plan of care orders included SN one time a week for one week and two times a week for eight weeks for: instruction and reinforcement of diabetic care; wound care to right lower extremity; obtain oxygen saturation at each visit; and observation, assessment, and education for hypertension management, fall risk, comorbid conditions, cardiovascular system, infection control and prevention, hospital readmission, pain management, heart failure management, and peripheral edema. a. The agency failed to ensure all medications and treatments were included on Patient #3's POC. Review of Patient #3's POC dated 7/3/23 to 8/31/23 and the previous POC dated 5/4/23 to 7/2/23 both revealed durable medical equipment (DME) which included diabetic supplies, elevated toilet seat, glucometer, grab bars, hospital bed, shower chair, shower wand/hand held sprayer, walker, dressing-compression and wound care supplies. Review of SN interventions on the POCs failed to reveal treatment interventions for the juxtalite compression wrappings which indicated when Patient #3 was to wear the wrappings, for how long and who would don the wrappings and doff the wrappings. Review of SN #5's service documentation between 6/4/23 to 8/21/23 revealed SN #5 had provided assistance to Patient #3 in donning his juxtalite compression wrappings on the following 12 dates: 6/2/23, 6/5/23, 6/9/23, 6/13/23, 6/16/23, 7/6/23, 7/22/23, 7/24/23, 7/27/23, 8/3/23, 8/9/23 and 8/17/23. Further review revealed on 7/22/23, SN #5 documented Patient #3 used juxtalite wraps, but was unable to put them on by himself so SN or caregiver had to do it for him and then he would leave them on until the night before someone was coming again. During an interview on 8/22/23 at 12:15 p.m., Patient #3 stated SN #5 assisted him in donning the juxtalite compression wrappings as Patient #3 was unable to independently don the wrappings; however, he was able to take these wrappings off independently. During an interview on 8/23/23 at 11:05 a.m., SN #5 stated Patient #3's physician had ordered the juxtalite compression wrappings and the order included donning the wrapping in the morning and doffing the wrappings at night. SN #5 reviewed Patient #3's POC and acknowledged the treatment interventions on how long Patient #3 was to wear his juxtatile wraps and who would assist Patient #3 in donning or doffing the wraps was not included within the POC and should have been. 2. The clinical record for Patient #5 was reviewed on 8/22/23. The POC for the period dated 7/31/23 to 9/28/23 revealed a start of care date of 7/31/23; diagnoses included unspecified open wound of the right lower leg, unspecified wound of the left lower leg, local infection of the skin and subcutaneous tissue, pseudomonas causing diseases classified elsewhere, plantar fascial fibromatosis, long term use of antibiotics and long term use of aspirin. POC orders included SN three times per week for two weeks, two times per week for six weeks, one time per week for one week for education and assessment on disease processes, ongoing physical assessment of integumentary system and pain management, wound care, fall risk assessments and vital signs; physical therapy (PT) one time per week for eight weeks for education and assessment of balance, gait, and mobility; occupational therapy (OT) one time per week for four weeks for education and assessment of use of DME, safety in the home and teaching in activities of daily living (ADLs); and Medical Social Worker (MSW) one time for evaluation. a. The agency failed to ensure all pertinent diagnoses were included on Patient #5's POC. Further record review of Patient #5's POC revealed SN interventions included assessment of integumentary status to identify change and intervene to minimize complications and provide teaching related to altered skin integrity including pathophysiology, nutrition, medication regime and methods to prevent pressure ulcers. Patient #5's POC also included the medication Furosomide 20 mg tablet to be administered one to two times per day to treat edema; a diagnosis not included on the POC. Review of the referral for home health services, received by fax on 7/28/23, revealed a diagnosis list which included bilateral edema of lower extremity, open wound on the left and right lower legs due to fluid seeping out of legs which created excoriation; bilateral plantar fasciitis, hypertension and morbid obesity. Review of the SOC comprehensive assessment, dated 7/31/23, completed by SN #11 revealed an integumentary assessment included Patient #5 had 4+ pitting edema in both right and left lower legs. Record review of SN #11's service documentation revealed documentation Patient #5 had edema BLE (bilateral lower extremeties); a diagnosis not listed on the POC, as well as SN #11 provided wound/edema/skin education including the benefits of good compliance with low salt, elevation and keeping dressing intact on the following seven dates during this certification period: -7/31/23 of 4+ edema; -8/2/23 of 4+ edema; -8/4/23 of 4+ edema; -8/7/23 of 4+ edema; -8/11/23 of 3+ edema; -8/14/23 of 3+ edema; and -8/17/23 of 3+ edema. During an interview at a home visit on 8/22/23 at 11:07 a.m. SN #10 stated SN #11 was not available for an interview during the survey and he was providing backup services to some of her patients. During an interview on 8/23/23 at 12:28 p.m., the director of clinical services (DCS) reviewed Patient #5's record and confirmed the POC failed to reveal diagnosis of bilateral edema which should have been included on the POC. The DON stated at time of referral, an intake nurse reviewed and entered all referral information, including diagnosis and medications, into the patient record and the SN case manager ongoing was expected to review and verify all pertinent diagnosis when writing SN interventions on the POC. 3. The clinical record for Patient #12 was reviewed on 8/21/23. The plan of care for the certification period dated 3/16/23 to 5/14/23 revealed a start of care date of 3/16/23; diagnosis included surgery on the digestive system, abnormal findings of the liver and biliary tract, sepsis with septic shock, chronic kidney disease, congestive heart failure, urinary tract infection, pneumonia, laceration of right upper arm, dementia, hyperlipidemia, and muscle weakness. Plan of care orders included SN one time a week for one week, two times a week for two weeks and one time a week for three weeks for wound care to right upper arm; obtain oxygen saturation at each visit; and observation, assessment, and education for dementia, fall risk, comorbid conditions, cardiovascular system, infection control and prevention, hospital readmission, pain management, medication profile and reconciliation, anticoagulation therapy regimen, and heart failure management; physical therapy one time a week for five weeks for evaluation, home exercise program development, functional mobility retraining, balance training, fall reduction education, and pain control; and occupational therapy one time a week for four weeks effective 3/19/23 for evaluation, home exercise program development, activities of daily living retraining, home environment safety recommendations, and fall reduction education. a. The agency failed to ensure all supplies and DME were included on Patient #12's POC. Record review of Patient #12's POC revealed DME which included grab bars, electric chair lift, shower chair, shower wand/hand held sprayer, toilet safety rails, walker, vital signs equipment and wound care supplies. Review of SN #5's documentation on 3/17/23, Patient #12 had a chole tube/drain placed on 2/16/23 and SN #5 emptied chole drain bag and provided education to Patient #12 and family caregiver on draining. Further review of service documentation revealed SN #5 provided observation and assessment of the chole drain and instruction to family caregivers to keep chole drain from hanging and pulling on insertion site on the following eight dates: 3/21/23, 3/24/23, 3/28/23, 4/1/23, 4/3/23, 4/7/23, 4/10/23 and 4/15/23. During an interview at a home visit on 8/22/23 at 11:07 a.m. SN #10 stated SN #11 was not available for an interview during the survey and he was providing backup services to some of her patients. During an interview on 8/23/23 at 12:32, the DCS reviewed Patient #12's POC and stated hand hygiene before and after drainage was documented as an SN intervention; however, confirmed the cholecyst drain supplies were not listed on the POC. 4. Similar findings of the failure to ensure all pertinent diagnosis were included on the POC were revealed in the record for Patient #2.

Conformance with physician orders CFR(s): 484.60(b) Standard: Conformance with physician or allowed practitioner orders. This STANDARD is not met as evidenced by: Based on interview and record review, the agency failed to ensure services were provided in accordance with physician's orders for 2 of 5 patient records reviewed who received skilled wound care (Patients #3 and #12). Findings include: AGENCY POLICY According to the policy, "Care Planning Process," revised May 2022 (in part): "Clinicians will inform the patient's physician (or other authorized licensed independent practitioner) of any changes that suggest a need to alter the plan of care. Changes must be written, dated, and signed by the professional making the changes." According to the policy, "Verification of Physician Orders," revised May 2022 (in part): "Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients." 1. The clinical record for Patient #3 was reviewed on 8/21/23. The plan of care for the certification period dated 5/4/23 to 7/2/23 revealed a start of care date of 3/10/22; diagnoses included venous insufficiency, congestive heart failure, kidney disease, diabetes, anemia, abnormalities of gait and mobility, uropathy, paralytic ileus, metabolic syndrome, cervicalgia, hyperlipidemia, rheumatoid arthritis, history of urinary tract infections, and non-pressure ulcers of right leg. Plan of care orders included skilled nursing (SN) visits one time a week for one week and two times a week for eight weeks for: instruction and reinforcement of diabetic care; wound care to right lower extremity; obtain oxygen saturation at each visit; and observation, assessment, and education for hypertension management, fall risk, comorbid conditions, cardiovascular system, infection control and prevention, hospital readmission, pain management, heart failure management and peripheral edema. Review of the plan of care for the certification period dated 7/3/23 to 8/31/23 revealed plan of care orders including SN visits one time a week for nine weeks for: instruction and reinforcement of diabetic care; assess for signs and symptoms for infection right buttocks fissure weekly; obtain oxygen saturation at each visit; and observation, assessment, and education for hypertension management, fall risk, comorbid conditions, cardiovascular system, infection control and prevention, hospital readmission, pain management and heart failure management. a) The agency failed to ensure wound care was provided in accordance with physician orders. i. Review of the plan of care for the certification period dated 5/4/23 to 7/2/23 revealed wound care orders for the right lower extremity stasis ulcer twice weekly which stated the SN was to cleanse the wound with wound cleanser, cover with Hydrofera blue and secure with Kerlix and Coban. Review of the SN visit note completed by Skilled Nurse (SN) #5 on 5/12/23 showed SN #5 documented the wound to the right lateral ankle had no visible openings, was covered with a thin scab and she left open to air. SN #5 failed to complete wound care in accordance with the physician orders authorized on the 5/4/23 to 7/2/23 plan of care. Further review of the clinical record failed to show SN #5 coordinated with Patient #3's physician to change or discharge the orders for wound care to the right lower extremity stasis ulcer. During an interview on 8/23/23 at 11:15 a.m., SN #5 reviewed the record for Patient #3 and stated she must have forgotten to inform the physician about the status of Patient #3's right lower extremity wound and confirmed she did not obtain a physician's order to stop the ordered wound care to the right lower extremity stasis ulcer. During the same interview, the Director of Clinical Services (DCS) confirmed SN #5 had not completed wound care to the right lower extremity stasis ulcer in accordance with physician orders and failed to receive updated orders to modify or discharge the wound care. ii. Review of the plan of care for the certification period dated 7/2/23 to 8/31/23 revealed orders for the SN to perform wound care to right buttocks fissure. Review of a verbal order dated 7/20/23 and signed by the physician on 7/25/23 revealed wound care orders for the right buttocks fissure to include application of "gauze or ABD [Army battle dressing-an extra thick primary or secondary dressing used to absorb moderate to heavily draining wounds] pad and tape daily." Review of a narratives documented on a visit notes by SN #5 showed the following: -on 7/22/23 Patient #3 had been educated to cover the right buttocks fissure with gauze and tape by the SN at the hospital, but he "changed his mind and decided to let the pull ups he bought catch the drainage"; -on 7/24/23, Patient #3 "continues to use depends to catch the drainage"; -on 7/27/23 and 7/31/22, SN #5 noted drainage from the right buttocks fissure had "decreased to small amounts of serosanguinous drainage" on 7/27/23 and "had a small amount of serosanguinous drainage" on 7/31/23, but failed to document any wound care completed to the site; -on 8/3/23, SN #5 noted the buttocks surgical site had "some slough" and Patient #3 was no longer wearing depends/pull ups because that were causing him irritation; -on 8/9/23, SN #5 documented Patient #3 continues to have serosanguinous drainage from the right buttocks fissure wound, he was unable to apply a bandage to this site and had stopped wearing briefs (depends/pull ups) due to increased irritation. -on 8/14/23, SN #5 documented the Penrose drain (a small latex tube placed to allow blood and fluids to move from the area of surgery to avoid collection of fluid under incision and causing infection) was removed and Patient #3 was instructed to leave the area open to air. Review of the clinical record from 7/20/23 to 8/14/23 failed to show SN #5 completed wound care to the right buttocks fissure in accordance with physician orders. Further review showed SN #5 failed to obtain updated physician orders to discharge the original physician order to cover the right buttocks fissure with gauze or ABD pad and tape daily following Patient #3's refusal. During an interview on 8/23/23 at 11:45 a.m., SN #5 stated when she spoke with Patient #3's physician, she was told to complete the wound dressing as documented on the updated plan of care dated 7/20/23 but the physician also stated the dressing may not stay on and it would be acceptable to allow the patient to just wear depends/pull ups. SN #5 confirmed did not not document that conversation with the physician in the record for Patient #3. She further stated she must have "forgotten" to call the physician and have the wound care order discharged. During the same interview, the Director of Clinical Services (DCS) confirmed SN #5 had not completed wound care to the right buttocks fissure in accordance with physician orders and failed to receive updated orders to modify or discharge the wound care. 2. The clinical record for Patient #12 was reviewed 8/21/23. The plan of care for the certification period dated 3/16/23 to 5/14/23 revealed a start of care date of 3/16/23; diagnoses included surgery on the digestive system, abnormal findings of the liver and biliary tract, sepsis with septic shock, chronic kidney disease, congestive heart failure, urinary tract infection, pneumonia, laceration of right upper arm, dementia, hyperlipidemia and muscle weakness. Plan of care orders included SN visits one time a week for one week, two times a week for two weeks and one time a week for three weeks for: wound care to right upper arm; obtain oxygen saturation at each visit; and observation, assessment, and education for dementia, fall risk, comorbid conditions, cardiovascular system, infection control and prevention, hospital readmission, pain management, medication profile and reconciliation, anticoagulation therapy regimen and heart failure management; physical therapy (PT) visits one time a week for five weeks for evaluation, home exercise program development, functional mobility retraining, balance training, fall reduction education and pain control; and occupational therapy (OT) visits one time a week for four weeks effective 3/19/23 for evaluation, home exercise program development, activities of daily living retraining, home environment safety recommendations and fall reduction education. a) The agency failed to ensure wound care was provided in accordance with physician orders. Review of the plan of care for the certification period dated 3/16/23 to 5/14/23 revealed wound care orders for the right upper posterior arm skin tear to include cleansing with wound cleanser, apply xeroform and cover with bordered foam using clean/aseptic technique twice weekly. Clinical record review showed SN #11 documented on 3/20/23 and 3/23/23 she "performed wound care to right upper arm and posterior loop lower leg sing (sic) xeroform, alginate and bordered foam." During an interview on 8/23/23 at 12:36 p.m., the DCS reviewed the visit notes and wound care orders for Patient #12 and confirmed Alginate was not listed on the wound care orders. She stated SN #11 did not provide wound care to Patient #12 in accordance with the physician's orders. SN #11 was not available for an interview. 3. During an interview on 8/22/23 at 1:48 p.m., the administrator stated, following the State Agency (SA) surveyor request for an interview with SN #5, the agency had initiated a review of the chart for Patient #3 and had identified "areas of opportunity for education" which the agency was then going to discuss the next day with agency clinicians. During an interview on 8/23/23 at 12:35 p.m., the DCS confirmed all treatments were required to be completed in accordance with physician orders and acknowledged SN #5 and SN #11 did not provide wound care per physician orders. She stated the agency would re-educate staff about following physicians orders.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure services and treatments were administered by agency staff only as ordered by a physician for 1 of 5 patients reviewed who had wound care (Patient #3). Findings include: AGENCY POLICY According to an agency policy, revised May 2022, titled, Verification of Physician Orders, (read in pertinent parts): "Orders will be obtained from a licensed physician (or other authorized licensed independent practitioner) for care and services to be provided to home health patients." 1. The clinical record for Patient #3 was reviewed on 8/21/23. The plan of care for the certification period dated 5/4/23 to 7/2/23 revealed a start of care date of 3/10/22; diagnosis included venous insufficiency, congestive heart failure, kidney disease, diabetes, anemia, abnormalities of gait and mobility, uropathy, paralytic ileus, metabolic syndrome, cervicalgia, hyperlipidemia, rheumatoid arthritis, history of urinary tract infections, and non-pressure ulcers of right leg. Plan of care orders included skilled nursing (SN) one time a week for one week and two times a week for eight weeks for: instruction and reinforcement of diabetic care; wound care to right lower extremity; obtain oxygen saturation at each visit; and observation, assessment, and education for hypertension management, fall risk, comorbid conditions, cardiovascular system, infection control and prevention, hospital readmission, pain management, heart failure management, and peripheral edema. Review of the plan of care for the certification period dated 7/3/23 to 8/31/23 revealed plan of care orders including SN one time a week for nine weeks for: instruction and reinforcement of diabetic care; assess for signs and symptoms for infection right buttocks fissure weekly; obtain oxygen saturation at each visit; and observation, assessment, and education for hypertension management, fall risk, comorbid conditions, cardiovascular system, infection control and prevention, hospital readmission, pain management, and heart failure management. a) The agency failed to ensure physician orders were obtained for care provided to Patient #3's buttock cyst. Review of Patient #3's clinical record failed to show any physician orders to drain Patient #3's right buttock cyst. Review of Patient #3's clinical record revealed SN #5 completed a recertification comprehensive assessment visit on 5/1/23 and documented, "was able to get a small amount of bloody drainage from cyst to buttocks." SN #5 failed to have an order to drain Patient #3's buttock cyst. Review of a SN note completed on 5/8/23 revealed SN #5 documented, "The cyst to his right buttocks is still draining. RN [registered nurse] only able to get a small amount of serosanguineous drainage (a wound draining fluid with both serum and red blood cells) out." SN #5 documented she did not complete care coordination during this visit. SN #5 failed to have an order to drain Patient #3's buttock cyst. Review of a SN note completed on 5/19/23 revealed SN #5 documented Patient #3 reported the cyst to his buttocks is bleeding more, and SN #5 assessed the cyst. SN #5 documented, "no visible opening, but there is blood in his depends and RN was able to get a small out by applying pressure." SN #5 documented she did not complete care coordination during this visit. SN #5 failed to have an order to drain Patient #3's buttock cyst. During an interview on 8/23/23 at 10:59 a.m., SN #5 stated Patient #3 complained of painful pressure at his right buttock cyst and asked her to try to drain the cyst to attempt to relieve his pain. SN #5 stated Patient #3's primary care physician (PCP) was aware Patient #3 had a painful draining cyst on his right buttocks, but confirmed she failed to obtain an order to drain the cyst prior to each time she had drained the cyst. b) The agency failed to ensure physician orders were obtained for the wound care provided to Patient #3's right shin wound. Review of Patient #3's clinical record from 5/1/23 to 8/21/23 failed to show physician orders for wound care to Patient #3's right shin wound. Review of a SN note completed on 5/15/23 revealed SN #5 documented Patient #3 had a new superficial wound to his right shin and SN #5 covered the wound with adaptic (a type of wound dressing meant to protect the wound while preventing the dressing from adhering to the wound) and gauze to protect the wound. SN #5 documented she did not complete care coordination during this visit. SN #5 failed to obtain an order for the wound care she provided to Patient #3's right shin wound. Review of a SN note completed on 5/22/23 revealed SN #5 documented Patient #3's right shin wound was almost healed and Patient #3 tolerated the following wound care without pain: cleansed with wound cleanser, covered with Hydrofera Blue (a wound care dressing that improves migration of cells to a wound and removal of drainage), secured with kerlix (rolled gauze) and Coban (a self-adherent elastic wrap that functions like a tape). SN #5 documented she did not complete care coordination during this visit. SN #5 failed to have an order for the wound care she provided to Patient #3's right shin wound. Review of SN note completed on 5/30/23 revealed SN #5 documented Patient #3's right shin was red, thus she covered his right shin with an abdominal pad (an extra thick primary or secondary dressing used to absorb moderate to heavily draining wounds) and wrapped Patient #3's right shin with kerlix and Coban. SN #5 documented she did not complete care coordination during this visit. SN #5 failed to have an order for the wound care she provided to Patient #3's right shin. During an interview on 8/23/23 at 11:17 a.m., SN #5 acknowledged she failed to obtain an order for the wound care she provided Patient #3's right shin on 5/15/23, 5/22/23 and 5/30/23. SN #5 stated when she applied the adeptic and gauze on 5/22/23 and the abdominal pad, kerlix and Coban on 5/30/23, she was attempting to protect Patient #3's skin so she did not consider the care she provided him wound care, thus, she did not call Patient #3's PCP to obtain orders for the care she provided. SN #5 stated Patient #3 had previously had a wound to his right shin and the wound care she provided him on 5/22/23 was from the order she had for his previous right shin wound, but could not recall how long ago the previous order was obtained. SN #5 and DCS both stated Patient #3 had been on services a long time and SN had provided care to many wounds for Patient #3. SN #5 stated she could not recall if she called Patient #3's PCP to obtain an order for this wound care; however, SN #5 stated the agency's electronic medical record (EMR) system would not allow her to reactivate the wound without an order. SN #5 reviewed Patient #3's record and failed to reveal an order for this wound care. During an interview on 8/22/23 at 11:30 a.m., the director of clinical services (DCS) acknowledged SN #5 failed to have orders for the wound care she provided Patient #3's right shin wound on 5/15/23, 5/22/23 and 5/30/23. The DCS stated the agency's EMR should prompt the SN to obtain an order if the SN reactivated care to a previous wound, but stated it is possible the EMR allowed SN #5 to reactive Patient #3's right shin wound and put the wound care protocol order from the last time Patient #3 received care to his right shin wound without obtaining a new order. c) The agency failed to ensure physician orders were obtained for wound care provided to Patient #3's right ankle wound. Review of Patient #3's clinical record revealed SN #5 documented a physician order on 8/11/23 for wound care to Patient #3's right ankle as follows: cleanse wound with wound cleanser, cover with Hydrofera Blue ready dressing and an abdominal pad, wrap with gauze and Coban and change twice a week. SN #5 documented this was not a verbal order and the order was signed by Patient #3's PCP on 8/21/23. There were no other physician orders for wound care for Patient #3's right ankle wound. Review of a SN visit note completed on 8/9/23 revealed SN #5 documented Patient #3's right lateral ankle wound had opened back up. SN #5 documented the wound was dry and SN #5 provided wound care to the wound (SN #5 failed to document what wound care she provided). SN #5 documented she did not complete care coordination during this visit. SN #5 failed to obtain an order for the wound care she provided to Patient #3's right lateral ankle wound. Review of SN visit notes completed on 8/11/23, 8/14/23, and 8/17/23 revealed SN #5 documented on 8/11/23, Patient #3's had a right lateral ankle stasis ulcer that opened back up. On 8/11/23, 8/11/23 and 8/17/23, SN #5 provided the following wound care: cleaned wound with wound cleanser, covered the wound with Hydrofera Blue ready and abdominal pad, and wrapped the wound with gauze and Coban. SN #5 documented on all three visits she did not complete care coordination during these visits. SN #5 failed to document when she obtained a verbal order for the wound care she provided to Patient #3's right lateral ankle wound she received from Patient #3's PCP. During an interview on 8/23/23 at 11:59 a.m., SN #5 stated the wound care she provided to Patient #3 on 8/9/23 was the same wound care she provided on 8/11/23, 8/14/23 and 8/17/23. SN #5 stated she did obtain an order from Patient #3's PCP for the wound care she performed to Patient #3's right lateral ankle wound on 8/9/23, 8/11/23, 8/14/23 and 8/17/23, but acknowledged she failed to document she spoke with Patient #3's PCP to obtain this order on 8/11/23 and the written order was not signed by the PCP until 8/21/23. The DCS acknowledged the order written on 8/11/23 failed to show a verbal order was obtained and was not signed until 8/21/23. 2. During an interview on 8/23/23 at approximately 12:35 p.m., the DCS stated all treatments provided by agency staff required a physician order. The DCS stated re-education would be provided to staff on this regulation.