Every finding on record at Honorcare Home Health Inc

Purpose of Visit: Re-Certification Entrance: 12/6/22 at 9:16 a.m., with the Administrator Agency Census: Licensed and Certified (L&C) – 0 Licensed Home Health (LHH) – 0 Personal Assistance Services (PAS) – 0 An exit conference was conducted on 12/8/22 at 11:40 a.m., with the Administrator and the Supervising Nurse. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. EPRP – Emergency Preparedness and Response Plan DC – Disaster Coordinator ADC – Alternate Disaster Coordinator

Plan Based on All Hazards Risk Assessment CFR(s): 484.102(a)(1)-(2) §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice's ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to have a written emergency preparedness and response plan based on a risk assessment that thoroughly described its approach to dealing with a disaster that could or did affect its services, in that: the risk assessment did not include a pandemic (worldwide infection). This deficient practice could place the future clients at risk of receiving inadequate care and services during a disaster if the agency is not prepared for either man-made or natural disasters. The findings included: Review of the agency’s risk assessment revealed hurricanes, tornados, and flooding were probable risks. There was no documented evidence that included a pandemic as a known risk. 2. During an interview on 12/6/22 at 1:30 p.m., with the Administrator and the Supervising Nurse, she stated that the agency had not updated the risk assessment and that pandemic/infections should have been added. The Administrator further stated that the agency prepared and implemented respiratory precautions and distributed PPE during the Covid (worldwide respiratory infection) pandemic. 3. Review of the agency’s “Emergency Preparedness” (EC08) (plan) undated revealed in part “The agency will take the following actions to develop, maintain, and implement and emergency preparedness and response plan: 4. As part of the EPRP development the agency will conduct a risk assessment to identify the potential disasters from natural and made-made causes most likely to occur in the agency’s service area…”

HHA- Procedures for Follow up Staff/Pts. CFR(s): 484.102(b)(3) §484.102(b)(3) Condition of Participation: [(b) Policies and procedures. The HHA must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (3) The procedures to follow up with on-duty staff and patients to determine services that are needed, in the event that there is an interruption in services during or due to an emergency. The HHA must inform State and local officials of any on-duty staff or patients that they are unable to contact. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to include in their EPRP a procedure that the agency must inform state and local officials of any on-duty staff or patients that they are unable to contact. This deficient practice places the future clients at risk for receiving inadequate care if the agency could not account for its staff and patients and communicate effectively with state and local officials during a disaster. The findings included: 1. Review of the agency’s “Emergency Preparedness Plan Addendum” (undated) revealed in part “Upon the event of an internal or external disaster, the agency’s communication tree will be implemented as follows: 1. The DC/ADC will contact the agency owners, according to the phone tree. 2. The DC will contact ADC to contact staff. 3. The DC will contact Office Support Staff. 4 Office Support will contact ancillary services. 5. The staff will contact clients. All personnel/titles listed above will document all successful and non-successful attempts to contact the staff they are responsible for….” The policy failed to include the requirement to inform State and local officials of any on-duty staff or patients the agency was unable to contact. 2. During an interview on 12/6/22 at 1:30 p.m., with the Administrator and the Supervising Nurse they stated that they did not know that they had to let local and state officials know of on-duty personnel that the agency was unable to contact during a disaster. They further stated that they did not know that had to be included in the plan either and stated “Yes, I can see that is important.”

Purpose of Visit: Re-Certification Entrance: 12/6/22 at 9:16 a.m., with the Administrator Agency Census: Licensed and Certified (L&C) – 0 Licensed Home Health (LHH) – 0 Personal Assistance Services (PAS) – 0 An exit conference was conducted on 12/8/22 at 11:40 a.m., with the Administrator and the Supervising Nurse. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of receipt of the Statement of Deficiencies. SN – Skilled Nurse SOC – Start of Care POC – Plan of Care EPRP – Emergency Preparedness and Response Plan DC – Disaster Coordinator ADC – Alternate Disaster Coordinator THHSC – Texas Health and Human Services Commission iQUES – Internet Quality Improvement Evaluation System OASIS – Outcomes Assessment and Information Set CMS – Centers for Medicare and Medicaid prn – when needed FM – Family Member ADL – Activity of Daily Living CVA - Cardiovascular Accident QAPI – Quality Assurance Performance Improvement RN – Registered Nurse HHA – Home Health Agency N/A – Not Applicable SOM – State Operations Manual S&C – Survey and Certification MAC – Medicare Administrative Contractor PPE – Personal Protective Equipment

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 completed OASIS assessment data to the CMS system within 30 days of completing the assessment for one of one discharged patient (Patient #3) whose records were reviewed in that, there was no transfer OASIS sent to CMS after the client transferred on 5/2/21. This deficient practice places the agency out of compliance with transmitting/reporting of OASIS data. The findings included: 1. During the entrance conference on 12/6/22 at 9:16 a.m., with the Administrator the surveyor requested the 2021 and 2022 OASIS Agency Final Validation reports. 2. Review of the “OASIS Agency Final Validation” submission date 3/15/21 revealed CMS accepted the OASIS recertification submission completed on 2/27/21 for Client #3. Review of the “OASIS Agency Final Validation” submission date 12/6/22 (performed during the on-site review) revealed CMS accepted the submission of Client #3’s recertification completed on 4/29/21 (for certification period from 3/2/21 through 4/30/21). There was no documented evidence that the agency submitted OASIS data on Client #3 when he was transferred to the hospital on 5/2/21 and did not return to the agency. Further review revealed the agency had not informed the State that the agency had not transmitted OASIS data to CMS due to low census. 3. During a telephone interview on 12/7/22 at 11:15 a.m., with the Administrator, the Supervising Nurse, and the THHS OASIS Coordinator, the Supervising Nurse stated that she completed the transfer summary and sent it to the main office but someone at the main office transmits the data to CMS. She further stated, “I do not know why it was not transmitted” and the person authorized to do so was not available. The Administrator and the Supervising Nurse stated that they did not know they had to inform the state and CMS that the agency had no patients and that was why they had not been transmitting data. They stated they did not remember receiving anything either by phone, e-mail, or by letter that the agency had to let the state know why they had no patients and were not transmitting OASIS data. 4. Review of the “OASIS Compliance for Agency” (attestation form) signed and dated by the Administrator on 12/6/22 (during the survey) revealed in part “This agency has not transmitted any production OASIS data to the state OASIS system since 3/15/21 through 12/5/22 because all our patients have been discharged; the last patient discharged on 5/5/21 (was checked).” 5. Review of the “Provider Letter19-22 titled Mandatory Reporting of Outcome and Assessment Information Set (OASIS) Data” Issued date 9/25/19 revealed that CMS Certified HHA: According to CMS OASIS CoPs, OASIS Data is required to be collected & submitted to CMS for all adult (18 years old or older) patients receiving skilled care services whose pay source is Medicare/Medicaid (Traditional, HMO/ Managed Care, Advantage Plans, State Waiver Plans); care paid by Federal funds. d Review of a policy (untitled and undated) revealed “The Agency will follow CMS policy for Oasis submission. The agency will electronically transmit accurate, completed and encoded OASIS data to a centralized data submission system within 30 days of the completion of the assessment.” Additional information was provided by the agency on 12/12/22 via e-mail revealed "OASIS Compliance for Agency Attestation" signed and dated by the Administrator on 12/12/22 revealed the agency has not admitted patients since 8/1/22."

Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA's internal policies. (4) When services are provided on the basis of a physician or allowed practitioner's verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA's policies, must document the orders in the patient's clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA's internal policies. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce a written policy that addressed the time frame for the physician’s countersignature for two of four discharged patients (Patients #1 and #2) whose records reviewed, in that the initial orders and POC were not signed by the physician. This deficient practice places the agency’s future patients at risk of receiving inadequate care when orders are not authorized by the licensed independent practitioner. The findings included: 1. Review of the Patient #1’s clinical record revealed a SOC on 7/15/22 with a POC certification from 7/15/22 through 9/12/22 with a diagnosis of “Other Specified Anxiety Disorder and Repeated Falls with a SN frequency of one time a week for 9 weeks.” Further review revealed the POC was not signed, and the patient was discharged on 8/12/22 due to the patient’s insurance authorization was denied. Review of the “Physician Order dated 7/15/22 (electronically signed by the Supervising Nurse) revealed “Patient assessed for admission to home health services for certification period from 7/15/22 thru 9/12/22. Skilled Nurse frequency: one time a week for 9 weeks (1 w 9) pending authorization.” Further review revealed the patient’s order was not signed by the physician. 2. Review of Patient #2’s clinical record revealed a SOC on 7/11/22 for a POC certification from 7/11/22 through 9/8/22 with a diagnosis of Diabetes (high blood sugar levels) with a SN frequency of one time a week for eight weeks (1 w 8) and two prn visits. Further review revealed the patient was discharged on 8/5/22 due to the patient’s insurance authorization was denied. Review of the “Physician Order” dated 7/15/22 (digitally signed by the Supervising Nurse) revealed “Patient assessed on 7/15/22 for admission to home health services for certification 7/15/22 thru 9/8/22. Skilled Nurse frequency: 1w8 plus 2 prn for exacerbation (made worse) of disease process pending authorization.” There was not documented evidence that the physician’s order was signed. 3. During an interview on 12/6/22 at 2:30 p.m. and at 3:05 p.m., with the Supervising Nurse, she stated that normally a patient was referred by a physician, or a hospital, but Patients #1 and #2’s FMs were providers from their sister agency (unlicensed worker that assisted patients with ADLs) and referred them to home health. She further stated that she called the physicians, and they gave her a verbal order to start home health. She added that she did not have the physicians sign the verbal orders. During an interview on 12/7/22 at 9:15 a.m., with the Administrator she stated that the physician orders should be signed and completed on time. 4. Review of the agency’s policy titled “Verification of Physician Orders” 10/2009 revealed in part 9. “The original order will be delivered to the physician’s (or authorized licensed independent practitioner) for his/her signature. Signed orders will be placed in the clinical record within 30 days of initiation of the order unless otherwise specified by applicable state law and regulation. The unsigned copy of the order will be removed from the record…”

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 record review and interview, the agency failed to enforce written policies to control infections and communicable diseases that included requirements to document infections that the patient acquired while receiving services from the agency in that there was no documented evidence of a primary diagnosis, patient’s signs and symptoms, pathogens identified, and treatment documented on the infection log. This deficient practice places the future patients at risk of the spread of infections when the agency does not track and trend infection data on infections acquired at the agency. The findings included: 1. Review of discharge Patient #3’s clinical record revealed a SOC on 5/6/20 for a certification period from 5/1/21 through 5/5/21 with a diagnosis of Paraplegia (This usually happens because of injuries to the nervous system, especially the spinal cord) and had an indwelling urinary catheter (a tube inserted into the bladder that drain urine into a bedside drainage bag). Further review revealed he received SN visits twice a week for eight weeks to perform nephrostomy tube (thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects) dressing changes and care of urinary catheter tubing changes every 2-3 weeks. In addition, the agency was notified that the patient was transferred on 5/2/21 and was admitted to the hospital for Sepsis (bacteria in the blood) and kidney failure (kidneys not working to clean the blood). Review of the “Infection Control Log” revealed date of onset was 5/2/22 “Site of Infection Sepsis with renal failure waiting on hospital paperwork for site of infection.” Further review of the clinical record revealed there was no documented evidence that a “Infection Identification-Patient Report” was completed. 2. During an interview on 12/7/22 at 3:20 p.m., with the Supervising Nurse she stated all agency acquired infections should be documented on the infection log and a “Patient Report” completed. She further stated that she did not complete a report and did not obtain the information from the hospital, and she should have. She did not remember why she didn’t. 3. During an interview on 12/7/22 at 3:35 p.m., with the Administrator she stated that infection data needs to be tracked to prevent infections in the agency. 4. Review of the agency’s policy titled “Evaluation and Maintaining Records of Infections Among Patients” dated 11/2009 revealed in part “1. The Infection Identification-Patient Report Form is completed when any of the following occur: D. A patient is admitted to a hospital due to an actual or suspected infection…”

Licensing CFR(s): 484.100(b) (b) Standard: Licensing. The HHA, its branches, and all persons furnishing services to patients must be licensed, certified, or registered, as applicable, in accordance with the state licensing authority as meeting those requirements. This STANDARD is not met as evidenced by: Based on record review and interview the agency failed to comply with applicable federal and state requirements for licensing in that: 1. The agency did not report a change in its physical location to CMS, and 2. The agency did not display a current THHSC license (last one issued on 10/3/22). This deficient practice places the agency’s future clients at risk of not know whether the agency was a certified and licensed provider and inability to conduct a survey if CMS does not have the correct address. The finding included: 1. During pre-survey record review by the Surveyor on 12/5/22 revealed on iQUES (a CMS website that manages provider and client information) revealed the agency’s address was 7551 Callaghan Road, Suite 105, San Antonio, Texas, 78229. Review of the Texas Unified Licensure Information Portal (TULIP) (collects data on each licensed agency in the state) dated 12/5/22 (pre-survey) revealed the following: License Print Date: 11/2/18, License Mail Date: 11/5/18, License Effective Date: 6/30/18, and License Expiration Date: 10/31/22. Further review of the TULIP Portal (a portal that contains information about the agency) dated 12/5/22 revealed the agency’s location was 7551 Callaghan Road, Suite 102 A, San Antonio, Texas, 78229. Review of the THHSC “Notification of Change” dated 6/26/17 revealed the change to Suite 102 A became effective on 6/1/17. Review of a screen shot (undated) of the TULIP Portal (provided by the Administrator) revealed the agency’s license renewal application was “in review” as of 8/25/22 and the current license expired on 10/31/22. 2. During entrance conference on 12/6/22 at 9:16 a.m., (conducted at 7551 Callaghan Road, Suite 102 A) with the Administrator, the Surveyor requested a copy of the agency’s license and was provided with THHSC license #015338 with an expiration date of 6/30/20. In addition, the Administrator stated the agency informed the state of the suite change but was not sure the agency informed CMS. She stated that she would have to find out from their main office in Houston. 3. During an interview on 12/6/22 at 10:35 a.m., with the Administrator she stated “Oh, this license is old.” She further stated that this license was the only one she had and denied that she received an updated license. She further stated she would have to talk with the business office to find out why the 10/31/22 license was not at the agency. She added that the business office informed her that they sent in the renewal information on 8/25/22 and it was still pending approval and was under review. Finally, she stated she did not know why an old license was displayed. During a phone conversation on 12/7/22 at 10:15 a.m., with the Administrator, the Supervising Nurse, and the THHS OASIS Coordinator she stated that CMS had Suite 105 on file for the agency. The Administrator stated that she could not find the CMS Form 855A (Change of Address) and thought that since she notified the state that it was sufficient and did not notify CMS. The Administrator further stated that their main office will continue to look for the Form 855A. 4. Review of the “Job Description: Administrator” (signed and dated by the Administrator) 10/3/16 revealed in part “Duties: D. Be familiar with State and Federal Requirements and arranging for Agency compliance with the same… 5. Review of the CMS Center for Clinical Standards and Quality/Survey and Certification Group Reference S&C 14-14-HHA (revised date 5/20/2014) revealed in the SOM Manual 2185, chapter 2 (page 142 of 467) revealed the HHA must notify CMS using CMS Form 855A of changes in location within 30 days. Further review reveal “It is inherent in the provider certification process that a provider notifies CMS of its intent to change the location or site from which it provides services. Absent such notification, CMS has no way of carrying out its statutorily mandated obligation of determining whether the provider is complying with applicable participation requirements at the new site or location. It is longstanding CMS policy that there is no basis for a provider to bill Medicare for services provided from a site or location that has not been determined to meet applicable requirements of participation. When an existing HHA intends to move from its surveyed and certified location to a new site or location that is within the current approved geographic area, it notifies its MAC within 30 days of the move, and submits all required documentation including an amended Form CMS -855A…”

Must have a written agreement CFR(s): 484.105(e)(2)(i-iv) An HHA must have a written agreement with another agency, with an organization, or with an individual when that entity or individual furnishes services under arrangement to the HHA's patients. The HHA must maintain overall responsibility for the services provided under arrangement, as well as the manner in which they are furnished. The agency, organization, or individual providing services under arrangement may not have been: (i) Denied Medicare or Medicaid enrollment; (ii) Been excluded or terminated from any federal health care program or Medicaid; (iii) Had its Medicare or Medicaid billing privileges revoked; or (iv) Been debarred from participating in any government program. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to enforce a contract between it and an independent contractor that performed services of the agency for one of two therapy contracts (Contract #1) whose contracts were reviewed, in that the contract did not designate that the HHA would maintain overall responsibility and include: 1. The manner in which services would be coordinated and evaluated by the agency. 2. The procedures for: submitting information and documentation by the contractor in accordance with the agency’s patient record policies, scheduling of visits by the contractor or the agency, and periodic patient evaluation by the contractor. This deficient practice places the agency’s future patients at risk of receiving inadequate care and services when the contractor does not know what is expected of them. The findings included: 1. Review of Contract #1 dated 3/24/22 revealed there was no documented evidence of the way services would be coordinated and evaluated by the agency; procedures for: submitting information and documentation by the contractor in accordance with the agency’s patient record policies, scheduling of visits by the contractor or the agency, and periodic patient evaluation by the contractor. 2. During an interview on 12/8/22 at 9:00 a.m., with the Administrator she stated that “We (the agency) never had anyone look through the contract as you are…with a fine-tooth comb.” She further stated that this could impact client care if each party did not know what was expected or responsible to do certain things. 3. Review of the agency’s policy titled “Written Agreements for Contracted Services” dated 11/2009 revealed “Senior management will be responsible for the availability of qualified care and services to meet the needs of the patients served. When the organization provides care and services through another source, the patients are entitled to the same level of performance from that source as from the organization itself…1. The written agreement between the organization and the contract service/individual will define the nature and scope of services…B 2. The scheduling of visits, shift, or hours, C. What documentation the organization requires, and the time frame for completing the documentation…4. As part of the organization’s annual evaluation process the Administrator will monitor, evaluate, and audit the contracted services…”

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain an accurate patient record for two of four discharged patients (Patients #1 and #2), whose records were reviewed, in that: 1. The Triage Code (for emergency disaster preparedness code) for Patient #1 was inaccurate on the POC. 2. The SOC for Patient #2 was inaccurate on the POC. This deficient practice places the agency’s future patients at risk of miscommunication and errors in care by the staff when the clinical record is not accurate. The findings included: 1. Review of Patient #1’s clinical record revealed a SOC on 7/15/22 with a POC certification period from 7/15/22 through 9/12/22 with a diagnosis of “Unspecified Anxiety and Recent Falls.” Further review revealed a SN frequency of one visit a week for nine weeks (1 w 9), and a “Emergency Preparedness Code” of “NA.” Review of the “Client Emergency Preparedness Plan” (a form used on admission to assign a triage code to a patient) signed and dated by the Patient #1’s FM on 7/14/22 revealed “Your disaster triage level is: Level III (low potential for adverse effect if visits are delayed 48-72 hours.)” 2. During an interview on 12/6/22 at 2:30 p.m., with the Supervising Nurse she stated the triage level was incorrect and she did not know why she wrote “N/A.” 3. Review of Client #2’s clinical record revealed a SOC on 7/11/22 for a POC certification from 7/11/22 through 9/8/22 with a diagnosis of Diabetes (high blood sugar levels) with a SN frequency of one time a week for eight weeks (1 w 8) and two prn visits. Further review revealed the client was discharged on 8/5/22 due to the client’s insurance authorization was denied. Review of the “Physician Order” dated 7/15/22 (digitally signed by the Supervising Nurse) revealed “Client assessed on 7/15/22 [sic] for admission to home health services for certification 7/15/22 thru 9/8/22. Skilled Nurse frequency: 1w8 plus 2 prn for exacerbation (made worse) of disease process pending authorization.” Record review of the “Face-to-Face Encounter” (unsigned) revealed “Episode: 7/15/22-9/8/22. Review of the insurance (Medicaid) authorization request revealed “Date/date range of service: 7/15/22 through 4/8/22.” 4. During an interview on 12/6/22 at 3:05 p.m., with the Supervising Nurse she stated that she sent the authorization for service on 7/11/22 to start services on 7/15/22 and visited the patient on 7/15/22. She further stated that the SOC was a typo on the POC and did not know why it happened. During an interview on 7/9/22 at 9:15 a.m., with the Administrator she stated that the charts needed to be completed and accurate to prevent errors in communication. 5. Review of the agency’s policy titled “Contents of the Clinical Record” date 11/2009 revealed in part “A clinical record will be maintained for each patient receiving care. The clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among organizations and contract personnel…”