Every finding on record at Interim Healthcare of Greater Denver Inc

A recertification in conjunction with a COVID 19 survey was completed on 3/4/21. Three deficiencies were cited.

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 interview and record review, the agency failed to ensure verbal orders by the qualified practitioner responsible for furnishing or supervising the ordered services were in accordance with state law to include the representative conferring the order, signed, dated and timed for 11 of 17 patient records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #9, #10, #13, and #14). Findings include: REFERENCE Home health agency Medicare manual (Publication 11), 204.2 E: "Use of Oral (Verbal) Orders: When services are furnished based on a physician's oral order, the orders may be accepted and put in writing by personnel authorized to do so by applicable state and federal laws and regulations, as well as by the home health agency's (HHA) internal policies. The orders must be signed and dated with the date of receipt by the registered nurse or qualified therapist (i.e., physical therapist, speech-language pathologist, occupational therapist, or medical social worker) responsible for furnishing or supervising the ordered services." REGULATION According to CODE OF COLORADO REGULATIONS 6 CCR 1011-1 Chapter 26 section 7.10 "(E)(1) If person-to-person contact was not completed or if awaiting a return response, all contacts and interactions shall be documented. The agency shall have a written policy regarding how the agency will intervene if the attending care provider cannot be contacted or does not respond timely. (1) All orders shall contain sufficient information to carry out the order, name of the physician, intermediate care provider and, if appropriate, representative conferring the order to the HCA." AGENCY POLICY According to the policy titled, "Entries into the Patient/Client Record", dated 1/13/18 (In pertinent part) "An employee as authorized by law or regulation may receive physician verbal orders for care/service. A verbal order clearly identifies: -Name of patient/client; -Date and time of verbal order received; -Care/Service to be provided; -Discipline to provide care/service; -Frequency and duration of care/service; -Supplies if applicable; and -The signature and title (e.g., RN [registered nurse], PT [physical therapy]) of the authorized employee accepting the orders. Verbal orders must be written out completely at the time of receipt and read back to the individual who gave the order for confirmation/verification of the order. Verbal orders are authenticated and dated by the physician in accordance with applicable state laws and regulations." 1. The clinical record for Patient #6 was reviewed on 3/2/20. The Plan of Care for the certification period dated 1/4/21 to 3/4/21, revealed a start of care date of 1/4/21; diagnoses included COVID-19, pneumonia due to coronavirus disease, acute respiratory failure with hypoxia, muscle weakness (generalized)and repeated falls. Plan of Care orders included physical therapy (PT) visits twice weekly for four weeks; occupational therapy (OT) visits once for one week, twice weekly for one week then once weekly for four weeks; speech therapy (ST) visits once weekly for eight weeks and certified nurse aide (CNA) visits twice weekly for four weeks to provide assistance with activities of daily living (ADL) tasks. a) The PT failed to document complete verbal orders for the plans of care as per regulation to include the name of the physician, intermediate care provider or the authorized representative conferring the order date and time the orders were received. Review of the plan of care for the certification period dated 1/4/21 to 3/4/21 revealed the clinician/therapist signature and date of verbal start of care was documented as a verbal order was obtained and electronically signed by PT #10 on 1/4/2021 at 9:48 p.m. Review of the start of care assessment dated 1/4/21 revealed PT #10 completed a visit to Patient #6 on 1/4/21 from 1:16 p.m. to 2:11 p.m. and documented she communicated with the physician regarding the start of home health care, medication reconciliation and PT plan of care. There was no documentation of the name of the person she received the order from to include the date and time it was received. Review of a Case Communication note electronically signed and dated 1/4/21 at 11:20 p.m. revealed PT #10 documented she spoke with a physician regarding medication reconciliation, duplicate drug therapy, major drug interactions with no change in orders received and she requested a call back within 24 hours with any new orders and on 1/5/21 no new orders were received and the medications on the plan of care were correct; however, there was no time documented when she actually spoke with the physician or that she received verbal orders for the plan of care. Clinical record review failed to show evidence of a complete verbal order to include the person conferring the order, date and time the order was actually received. During an interview on 3/4/21 at 12:49 p.m. PT #10 stated she usually documented who she spoke with to receive the verbal orders in a communication note but did not write the name on her assessment, she just usually put yes for communication with the physician. She further stated the date and time on the plan of care verbal order section was the date and time she finished documenting her assessment but not necessarily the time she received the verbal order. b) The OT failed to document complete verbal orders for the plans of care as per regulation to include the name of the physician, intermediate care provider or the authorized representative conferring the order date and time the orders were received. Review of the plan of care for the certification period dated 1/4/21 to 3/4/21 revealed the clinician/therapist signature and date of verbal start of care was documented as a verbal order was obtained and electronically signed by OT #11 on 1/7/2021 at 5:25 p.m. However, review of the OT assessment dated 1/7/21 revealed there was no documentation of physician contact by OT #11. During an interview on 3/4/21 at 2:38 p.m. OT #11 stated she usually put who she spoke with to receive a verbal order in a communication note but did not document it on her evaluation note or her plan of care orders. c) The ST failed to document complete verbal orders for the plans of care as per regulation to include the name of the physician, intermediate care provider or the authorized representative conferring the order date and time the orders were received. Review of the plan of care for the certification period dated 1/4/21 to 3/4/21 revealed the clinician/therapist signatures and dates of verbal start of care were documented as a verbal order was obtained and electronically signed by ST #7 1/7/2021 at 4:30 p.m. Review of the ST evaluation dated 1/7/21 revealed ST #7 documented yes to the physician being contacted and verbal orders were received; however there was no documentation of who she spoke to, or the date and time the verbal orders were received. During an interview on 3/4/21 at 1:51 p.m. ST #7 stated she usually had to leave a message for the physician on the provider phone line and waited for a phone call back. She further stated that who she received the verbal order was not documented on in the electronic medical record for Patient #6. d) The PT failed to document a complete verbal order with who conferred the order date and time for PT visit change and CNA discharge. Review of a PT Visit note dated 2/8/21 revealed PT #10 documented she communicated with the physician's office and there was a change in orders to discontinue PT; however, there was no documentation of who she spoke with or date and time and there was no documentation about the CNA services. Review of an order dated 2/8/21 revealed PT #10 documented effective week of 2/6/21 for PT visit once for one week and effective 1/29/21 to discontinue further CNA visits. During an interview on 3/4/21 at 12:48 p.m. PT #10 stated usually Patient #6's insurance and physician provider did not require a phone call to discontinue CNA services. She further stated she called the physician's office to get the verbal order to add one more PT visit to discharge the patient and probably just added the discontinue CNA services to the order since the patient was independent and the patient felt comfortable bathing on her own. 2. The clinical record for Patient #9 was reviewed on 3/4/20. The Plan of Care for the certification period dated 1/10/21 to 3/10/21, revealed a start of care date of 1/16/20; diagnoses included type 1 diabetes mellitus without complications, acute kidney failure, unspecified, essential (primary) hypertension, unspecified osteoarthritis, unspecified site and spondylosis without myelopathy or radiculopathy of the cervical region. Plan of Care orders included Skilled Nursing (SN) visits three times a day for assessment, education blood glucose (BG) monitoring and insulin injections. a) The registered nurse (RN) failed to document a complete verbal order to include who conferred the verbal order with the date and time and order was received as per regulation. Review of the plan of care for the certification period dated 1/10/21 to 3/10/21 revealed documentation of verbal order obtained and electronically signed by RN #13's on 1/8/21 at 2:43 p.m. but there was no documentation of who she received the verbal order from. Review of the recertification dated 1/8/21 revealed RN #13 documented she communicated with the physician; however, there was no documentation of who she spoke with or if she received a verbal order. Clinical record review failed to show documentation of a complete verbal order for the recertification plan of care to include who conferred the verbal order. During an interview on 3/4/21 at 3:14 p.m. RN #13 stated she did not always document who she received a verbal order from when she called for orders. She further stated she usually spoke to Patient #9's physician during a face to face conversation and received orders during those conversations. RN #13 stated she should record the information in the patient's record but did not always document the conversations with the physician or who she received verbal orders from. b) The RN failed to document a complete verbal order to include who conferred the order, date and time the verbal order was received. Review of an order that had an intervention dated 6/8/20 of assess/instruct for COVID 19 symptoms and had orders dated 1/27/21 at 7:36 p.m. to discontinue Lantus 10 units (u) every morning and begin Lantus 12 u every morning per a nurse practitioner's (NP) first name. This order was electronically signed and dated for 6/8/20 by RN #13. There was no last name of the NP. Review of the visit notes dated 1/27/21 revealed RN #13 visited Patient #9 to administer her insulin between 8:06 a.m. to 8:30 p.m. she documented "Message left with [NP's first name] about patient overall trend of increased blood sugar readings;" however there was no other documentation found in the clinical record of a call back from the NP. During an interview on 3/4/21 at 3:14 p.m. RN #13 stated Patient #9 was a "fragile diabetic" and the NP is usually at the facility where the patient resides. She further stated the order was not clear of when she actually received the verbal to change the Lantus insulin. She further stated documentation of conversations with practitioners had been overlooked because the agency clinician's usually used a text messaging application for communication coordination which did not get documented in the patient's record. 3. The clinical record for Patient #1 was reviewed on 3/2/20. The Plan of Care for the certification period dated 2/12/21 to 4/12/21, revealed a start of care date of 2/12/21; diagnoses included anorexia nervosa, encounter for adjustment and management of vascular access device, other specified hyperalimentation, abnormal weight loss, unspecified protein-calorie malnutrition and hypertensive heart disease with heart failure. Plan of Care orders included SN visits once for one week, three times for one week then weekly for assessment, education, peripherally inserted central line catheter (PICC) line dressing changes and lab draws weekly. a) The RN failed to document a complete verbal order to include who the order was received from with a date and time for the plan of care after her initial start of care assessment. Review of the start of care assessment dated 2/12/21 revealed RN #4 documented she communicated with the physician regarding the plan of care; however there was no documentation of what physician she communicated with or the date and time she had received verbal orders. Review of the plan of care revealed documentation a verbal order obtained and electronically signed by RN #4 on 2/12/21 at 8:18 p.m.; however, there was no documentation of who conferred the order or if the RN received the order from the physician or their representative. During an interview on 3/4/21 at 1:13 p.m. RN #4 stated she saw Patient #1 one time for the start of care assessment on a Friday night. She further stated she developed the initial plan of care. She further stated she did not recall who she spoke to at the physician's office that night, but most of the time she called the office, she spoke with the on call staff, or the physician covering. 4. The clinical record for Patient #7 was reviewed on 3/3/21. The Plan of Care for the certification period dated 2/19/21 to 4/19/21, revealed a start of care date of 2/19/21; diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertensive chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and history of falling. Plan of care orders included PT visits once weekly for one week, and then twice weekly for three weeks for instruction of exercises; OT visits once weekly for three weeks for right hand strengthening, family education, and modification of bathing equipment; and ST visits once weekly for eight weeks for instructions regarding swallowing and exercise techniques and assess feeding and swallowing ability. a) The PT failed to document complete verbal orders for the plans of care as per regulation to include the name of the physician, intermediate care provider or the authorized representative conferring the order date and time the orders were received. Review of the plan of care for the certification period dated 2/19/21 to 4/19/21 revealed the clinician/therapist signature and date of the verbal start of care was documented as a verbal order was obtained and electronically signed by PT #5 on 2/20/21 at 5:27 p.m. Review of the start of care assessment dated 2/19/21 revealed PT #5 completed a visit to Patient #7 on 2/19/21 from 11:05 to 12:10 p.m., and documented he communicated with the physician regarding the start of PT orders, canceling of CNA orders, and medication discrepancies. There was no time documented when he actually spoke with the physician or who the PT spoke to at the physician office. During a home visit on 3/2/21 at 4:08 p.m., with Patient #7 the PT #5 stated that sometimes when he calls the physician office he leaves a message for a return call to get the verbal orders. He went on to state that if he is driving, or with a patient, he does not write down the name of the person who he spoke to. b) The OT failed to document complete verbal orders for the plans of care as per regulation to include the name of the physician, intermediate care provider or the authorized representative conferring the order date and time the orders were received. Review of the plan of care for the certification period dated 2/19/21 to 4/19/21 revealed the clinician/therapist signature and date of verbal start of care was documented as a verbal order was obtained and electronically signed by OT #11 on 2/26/21 at 4: 21 p.m. However review of the OT assessment, dated 2/26/21, as well as the revision to plan of care orders, dated 2/26/21, revealed there was no documentation of physician contact by OT #11. During an interview on 3/4/21 at 2:38 p.m. OT #11 stated she usually put who she spoke with to receive a verbal order in a communication note but did not document it on her evaluation note or her plan of care orders. c) The ST failed to document complete verbal orders for the plans of care as per regulation to include the name of the physician, intermediate care provider or the authorized representative conferring the order date and time the orders were received. Review of the plan of care for the certification period dated 2/19/21 to 4/19/21 revealed the clinician/therapist signature and date of verbal start of care was documented a verbal order was obtained and electronically signed by ST #7 on 2/27/21 at 4:30 p.m. However review of the ST assessment, dated 2/27/21 revealed the a contact with the physician office, but does not state at what time the contact took place, nor who gave the orders at the physician office was. During an interview on 3/4/21 at 1:51 p.m. ST #7 stated she usually had to leave a message for the physician on the provider phone line and waited for a phone call back. She further stated that who she received the verbal order was not documented on in the electronic medical record for Patient #7. 5. Similar findings of clinicians documenting orders but did not document a complete order per regulations to include who the order was received from with the date and time was found for Patients #2, #3, #4, #5, #10, #13, and #14.

Revised plan of care CFR(s): 484.60(c)(2) A revised plan of care must reflect current information from the patient's updated comprehensive assessment, and contain information concerning the patient's progress toward the measurable outcomes and goals identified by the HHA and patient in the plan of care. This ELEMENT is not met as evidenced by: Based on interview and record review, the agency failed to ensure the plan of care contained patient's accurate current information and interventions based on updated comprehensive assessment of the patients for 2 of 7 active patients records reviewed who had a recertification assessment (Patient #3 and #10). Findings include: 1. The clinic record reviewed for Patient #10 on 3/3/20, revealed a start of care date of 12/16/20; diagnoses included chronic venous hypertension with ulcer and non-pressure chronic ulcer of other part of right lower leg with fat layer exposed. Plan of care orders for the certification period dated 2/14/21 to 4/14/21 included orders for skilled nurse (SN) visits for three visits weekly for one certification period for assessment, education, wound care for the venous stasis ulcer on the patient's right shin. a) The agency failed to ensure the registered nurse (RN) updated Patient #10's plan of care with accurate current information. Review of an order dated 1/27/21 revealed the wound clinic of Patient #10 changed the wound care orders for the patient to the following: cleanse wound with wound cleanser, pack wound with hydrofera blue pre moistened with saline, apply xeroform to the wound, secure wound with abd pad, soft cast padding, and double layer compression wrap. Review of the updated plan of care dated 2/14/21 revealed the following wound care orders: cleans wound with wound cleanser, apply Iodosorb impregnated into adaptic, cover wound with pleated visco paste and abd pad, secure with double layer compression wrap. This in contrast to the above written wound care orders. During an interview on 3/4/21 at 2:18 p.m., RN #12 stated that Patient #10 had gone to the wound clinic and had come back with new orders. She went on to state she thought she had created a revision to the plan of care order detailing the new orders, and had called it into the physician office to confirm the new orders. However there was no documentation that this phone call was made, or that a revision to the plan of care order was written by RN #12. During interview on 3/4/21 at 3:54 p.m., RN #16 stated she was the Quality Assurance (QA) nurse and was responsible for reviewing all the notes, and plans of care that are written. When asked if there was a reason for why the wound orders on the plan of care dated 2/14/21 did not match the wound care orders received from the wound clinic she said it would have been up to the clinician writing the revised plan of care to update wound care orders. She also stated that she could see how this was a problem. 2. The clinical record for Patient #3 was reviewed on 3/3/20 , revealed a start of care date of 12/10/20; diagnoses included chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity, non-pressure chronic ulcer of right calf with fat layer exposed, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, encounter for surgical aftercare following surgery on the circulatory system, and weakness. Plan of Care orders for the certification period dated 12/10/20 to 02/07/21 included orders for SN visits once for one week, four times for one week, then three visit weekly for seven weeks for assessment, education, wound care to the venous stasis ulcers on the patient's distal right calf, right proximal calf and two wounds on the right medial calf, and four as needed (PRN) visits for soiled dressing or acute illness; physical therapy (PT) visits once for one week, twice weekly for two weeks Occupational therapy (OT) visits once weekly for three weeks; and certified nurse aide (CNA) visits three times a week for six weeks to provide assistance with activities of daily living (ADL) tasks. The Plan of Care for the certification period dated 2/8/21 to 4/6/21 orders included SN visits twice weekly for assessment, education and wound care to the right lower extremity with two PRN visits for soiled dressing or acute illness. a) The agency failed to ensure the RN updated Patient #3's plan of care with accurate current information. Review of an order dated 1/15/21 revealed RN #3 documented a request to discharge the patient from CNA services effective 1/2/21 per the patient request since the patient is able to bathe and dress independently. Review of a recertification assessment dated 2/5/21 revealed RN #3 documented Patient #3 was mostly independent with bathing and dressing. However, review of the plan of care for the certification period dated 2/4/21 to 4/6/21, revealed an intervention for supervisory visits of the CNA every two weeks but there were no CNA visit frequency documented. During an interview on 3/4/21 at 2:00 p.m. RN #3 stated the agency's plan of care interventions were pulled from their assessment and if you remove something, it did not always carry over the plan of care. She further stated she discontinued the CNA visits but the supervision intervention was not removed from the current plan of care, but should have been.

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 interview and record review, the agency failed to ensure clinical records contained current and accurate documentation of patient's clinical notes, plans of care and orders for 5 of 12 active patient records reviewed (Patients #1, #3, #6, #7 and #9). Findings include: AGENCY POLICY According to the policy titled, "Contents of the Patient/Client Record," dated 1/13/18 (In pertinent part) "The following information is included in the record of each patient/client admitted to home care: -Specific and appropriate notes on the care/service provided; -All comprehensive assessments from the most recent home care admission; -Patient/client's Plan of Care or Service Plan; -Authenticated, legible and complete physician's or other licensed practioner's orders, as required by law and regulation; -Documentation of relevant communication to the patient's/client's physician and others involved in the patient's/client's care; -Any other information required by law or regulation. The following information is included in each patient/client record when applicable to the care/service the patient/client is receiving; -Any changes in the patient's/client's condition; -Appropriate information on each dose of medication administered by employees and the patient's response to the medication administration; -All interventions, including treatments, and services, and responses to those interventions; -Medication list including prescription and over-the-counter medications as well herbal supplements and vitamins; i) Ongoing updates to the medication list (e.g., new, changed, and discontinued medications)." 1. The clinical record for Patient #9 was reviewed on 3/4/20. The Plan of Care for the certification period dated 1/10/21 to 3/10/21, revealed a start of care date of 1/16/20; diagnoses included type 1 diabetes mellitus without complications, acute kidney failure, unspecified, essential (primary) hypertension, unspecified osteoarthritis, unspecified site and spondylosis without myelopathy or radiculopathy of the cervical region. Plan of Care orders included Skilled Nursing (SN) visits three times a day for assessment, education blood glucose (BG) monitoring and insulin injections. a) The agency failed to ensure two orders were accurate with the date, time and registered nurse's electronic signature. Review of a Revision to Plan of Care order that had an intervention dated 6/8/20 to assess/instruct for COVID 19 symptoms and included orders dated 1/27/21 at 7:36 p.m. to discontinue Lantus 10 units (u) every morning and begin Lantus 12 u every morning per a nurse practitioner's (NP) first name. This order was electronically signed and dated for 6/8/20 by RN #13. It was unclear if the order was received on 6/8/20 as indicated on the RN's electronic signature or the date of 1/27/21. Review of a Revision to Plan of Care dated 2/22 had interventions for medication education, call physician, endocrine alteration and medication management revealed RN #13 documented an update order to notify the physician if the BG was less than 60 /or greater than. It had an electronic signature for RN #13 dated 6/8/20. During an interview on 3/4/21 at approximately 1:30 p.m. RN #17 stated the electronic medical record (EMR) showed a version of a document every time it was edited or changed and both orders had two versions, one with RN #13 and the second of RN # when she reviewed and approved the order. She further stated she was unsure why the electronic signature had a date different than the orders. During an interview on 3/4/21 at 3:14 p.m. RN #13 stated she thought Patient #9's insulin was changed on 1/27/21 and she was not sure why it had her electronic signature as 6/8/21. During an interview on 3/4/21 at 3:54 p.m. RN #16 stated she reviewed the plans of care, physician orders, assessments and evaluations. She further stated she was not sure why the electronic signature for RN #13 was different from the interventions and order dates and stated she could not change the dates for the signatures. RN #16 stated she was not sure why the date was different but should have been when the RN had put the order in. b) The SN failed to ensure the documentation of insulin administered was documented and accurate. Review of the plan of care for the certification period dated 1/10/21 to 3/10/21 revealed orders for the SN to administer insulin three times a day. Further review showed medications included Lantus 10 units (u) in the morning and 9 u in the evening, Humalog Kwikpen 5 u every morning and 6 u at noon and in the evening. Review of a Revision to Plan of Care order dated 1/27/21 revealed RN #13 documented she received a verbal order to discontinue Lantus 10 u every morning and begin Lantus 12 u every morning. Review of the SN visit notes revealed the SN either documented the wrong dose of insulin given or did not document the amount of insulin given. Specifically; On the SN visit note dated 2/19/21 RN #13 documented she gave 5 units of Humalog instead of the ordered 6 u. On 1/16/21 noon visit, 1/30/21 noon visit, 2/6/21 noon visit, 2/20/21 noon visit, and 2/27/21 the noon visit, licensed practical nurse (LPN #14) documented he held Patient #9's insulin and let the facility staff know but there was no documentation of communication to the RN or physician. LPN #15 on 1/13/21 evening visit no insulin documented, 1/26/21 evening visit she documented she gave 12 u of Lantus instead of the ordered 9, on 2/4/21 the morning visit no insulin was documented and in the evening she documented she gave 12 u of Lantus instead of the ordered 9 u, 2/9/21 noon visit no insulin documented, 2/21/21 evening visit no insulin documented and 2/25/21 for the morning visit she documented Humalog 5 u twice and no Lantus insulin. LPN #18 documented on 2/6/21 he administered 5 u of Humalog but did not document the Lantus; however, he documented he gave both insulins in his narrative note but no amounts. On 2/19/21 RN #13 documented she administered 5 u of Humalog insulin instead of the ordered 6 u. During an interview on 3/4/21 at 3:14 p.m. RN #13 stated Patient #9 was a "fragile diabetic" and the LPNs had reported to her using tiger text (a secure text messaging application) any low blood sugars or when they held the insulin but she did not know if they documented it on their visit notes. She further stated for the 2/19/21 visit she accidentally documented the 5 u instead of the ordered 6 u because there was both in the medication record and she selected the wrong one. The LPNs were unable to be interviewed. During an interview on 3/4/21 at 4:15 p.m. the Administrator stated the agency used tiger text as coordination of care between disciplines but it was not part of the clinical record. She further stated the clinicians were supposed to document the communication and coordination done in tiger text also in a communication note but they were not doing it for all communication. 2. The clinical record for Patient #3 was reviewed on 3/3/20 , revealed a start of care date of 12/10/20; diagnoses included chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity, non-pressure chronic ulcer of right calf with fat layer exposed, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, encounter for surgical aftercare following surgery on the circulatory system, and weakness. Plan of Care orders for the certification period dated 12/10/20 to 02/07/21 included orders for skilled nurse (SN) visits once for one week, four times for one week, then three visit weekly for seven weeks for assessment, education, wound care to the venous stasis ulcers on the patient's distal right calf, right proximal calf and two wounds on the right medial calf, and four as needed (PRN) visits for soiled dressing or acute illness; physical therapy (PT) visits once for one week, twice weekly for two weeks Occupational therapy (OT) visits once weekly for three weeks; and certified nurse aide (CNA) visits three times a week for six weeks to provide assistance with activities of daily living (ADL) tasks. a) The agency failed to ensure CNA supervisory visits were completed and documented every 14 days and identified as late entries. Clinical record review on 3/3/21 failed to show evidence any CNA supervisory visits were completed. A request was made for the CNA supervisory visits for Patient #3 on 3/3/21 at 2:17 p.m. On 3/4/21 at 4:00 p.m. the Director of Clinical Services (DCS) brought in two supervisory visits dated 12/16/20 and 12/30/20 which was electronically signed by RN #3 on 3/3/21. The DCS stated RN #3 had just put the visit notes in the electronic medical record (EMR). During an interview on 3/4/21 at 2:01 p.m. RN #3 stated supervisory visits were supposed to be completed every 14 days and documented either in a visit note or a separate supervisory form in the EMR. She further stated she completed a supervisory visit in person on 12/16/20 and another one two weeks later on 12/30/20 but did not electronically sign them until 3/3/21 and it was not identified as a late entry. 3. The clinical record for Patient #7 was reviewed on 3/3/21. The Plan of Care for the certification period dated 2/19/21 to 4/19/21, revealed a start of care date of 2/19/21; diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertensive chronic kidney disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and history of falling. Plan of care orders included Physical Therapy (PT) visits once weekly for one week, and then twice weekly for three weeks for instruction of exercises; Occupational Therapy (OT) visits once weekly for three weeks for right hand strengthening, family education, and modification of bathing equipment; and Speech Therapy (ST) visits once weekly for eight weeks for instructions regarding swallowing and exercise techniques and assess feeding and swallowing ability. a) The agency failed to ensure that the clinical record for Patient #7 was entered in a timely manner including communication notes in the delay of other discipline assessments. Review of the Clinical Record for Patient #7 revealed a referral form dated 2/18/21 for home health orders including PT, OT, and ST. Review of the Clinical Record revealed the OT start of care assessment did not occur until 2/26/21 and the ST start of care assessment did not occur until 2/27/21. Review of the case communication notes revealed a note created on 3/4/21 by OT #11. The note stated that the OT assessment was delayed due to the client not returning phone calls and voicemails. During an interview on 3/4/21 at 2:38 p.m., OT #11 stated that she was communicating with the other clinician via a secured message system about the delay to do the assessment. When asked why she entered the case communication note until the day of 3/4/21, six days after she was able to do the assessment, she stated that it was her negligence of not putting the information in the case communication note earlier. Review of the case communication notes revealed a note created on 3/4/21 by ST#7. The note stated that the ST assessment was delayed due to the client not returning phone calls and voicemails During an interview on 3/4/21 at 1:51 p.m., ST #7 stated she had put in the note concerning the late assessment that day. When asked why the note was put in five days late the ST stated she had just seen Patient #7 this weekend, and was just doing her notes for the weekend now. 4. Similar findings of missing, inaccurate, current information or documentation not identified as a late entry was found for Patients #1 and #6.