Every finding on record at Omnicare Associates Inc

On 06/20/2024 a Re-certification survey entrance was conducted. The agency was found in compliance with 42 CFR Part 484.22 Emergency Preparedness Requirements for Home Health Agencies and no deficiencies were cited. Census: Licensed and Certified: 123 Licensed Home Health: 0

On 06/20/2024 a Re-certification survey entrance was conducted. Census: Licensed and Certified: 123 Licensed Home Health: 0 An exit Conference was conducted on 06/28/2024 with the Administrator at approximately 1:30 PM. The preliminary findings were discussed. The agency was afforded the opportunity to provide additional information. Written instructions were provided for submitting a plan of correction within 10 days of the receipt of the Statement of Deficiencies. Abbreviations: OASIS -outcome and assessment information set CMS – Centers for Medicare and Medicaid Services IQIES – Internet Quality Improvement & Evaluation System

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 transmit completed Outcome Assessment Information Set (OASIS) assessments to the Centers for Medicare and Medicaid Services (CMS) system, within 30 days of completing the OASIS assessment (a tool used by CMS to collect certain patient information) of the beneficiaries (patients). From 01/01/2023 thru 06/18/2024 81 OASIS assessments were transmitted greater than 30 days from the assessment date. This Failure prevented the agency's patient data from being made available to CMS for analysis in order to identify agency performance levels in the provision of patient care. Pre-survey review of the report titled, “OASIS Error Detail Report” taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed 81 assessments contained error number -3330 with the error message of, “Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” During the entrance conference on 05/21/2024 at approximately 9:44 AM the surveyor and the Alternate Administrator discussed the OASIS report titled, “OASIS Error Detail Report.” The surveyor asked who was responsible for transmitting the OASIS reports to CMS. The Area Vice President stated, “I’m not sure who actually transmits or hits the button because there is a team that does that. I think they transmit on Monday, Wednesday and Friday but I’m not sure the person’s name.” The surveyor asked if the agency tracks how long it takes for an OASIS to be transmitted to CMS to assure it is completed within 30 days of the completion date. The Area Vice President stated, “We constantly monitor every step to make sure we know how long it takes and that we meet the guidelines.” The surveyor asked if the agency has had any issues with late transmittals of OASIS assessments.” The Administrator stated, “We run the reports and we haven’t had any problems. I think we have had maybe 1.” The surveyor reviewed the report titled “OASIS Error Detail Report” with the Administrator and the Area Vice President. The surveyor explained that from 01/01/2023 to 06/18/2024 the agency transmitted 81 OASIS greater than 30 days from the completion date (M0090). The surveyor asked why 81 transmittals were past 30 days. The Area Vice President stated, “I did not know we have had that many. That is news to me. I don’t know.” Record review for Patient 1: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 62883786 submission date 02/28/2024 with 7 total records processed. Record 4 (Patient 1) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 4 (Patient 1) of the OASIS Agency Final Validation report that was submitted on 02/28/2024 had a M0090 completion date of 12/01/2023. Record review for Patient 2: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 62741232 submission date 01/29/2024 with 15 total records processed. Record 12 (Patient 2) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 12 (Patient 2) of the OASIS Agency Final Validation report that was submitted on 01/29/2024 had a M0090 completion date of 12/27/2023. Record review for Patient 3: review of the agency OASIS final validation reports taken from the Internet Quality Improvement & Evaluation System (IQIES) revealed submission identification number 62943138 submission date 03/12/2024 with 6 total records processed. Record 4 (Patient 3) gave the following error: “…Message -3330 Warning… Message: Record Submitted Late: The submission date is more than 30 days after M0090 on this new record.” Record 4 (Patient 3) of the OASIS Agency Final Validation report that was submitted on 03/12/2024 had a M0090 completion date of 1/25/2024. On 6/20/2024 at approximately 2:45 PM the surveyor conducted an interview with the Administrator. The Administrator explained that she ran the late OASIS report for the agency from 5/1/2023 to 6/20/2024 and found 41 late OASIS submissions. The surveyor asked the Administrator why the agency had so many late OASIS submissions to CMS. The Administrator stated, “I know that’s a lot of late transmittals. I’m not sure why there are so many late transmittals. We will be adding that to our QAPI. I didn’t know we had that many.” On 06/28/2024 at approximately 10:45 AM the surveyor conducted an interview with the Administrator. The surveyor reviewed the findings from record review for Patients 1, 2, and 3. The surveyor explained that Patient 1, 2, and 3 each had an OASIS transmittal that was past 30 days from the completion dates. The surveyor asked why Patients 1, 2 and 3 had OASIS transmittals to CMS past 30 days from the completion date (M0090). The Administrator stated, “I think it’s just we had some new people in place, and they didn’t really have a complete understanding of the role for making sure the OASIS is being submitted within the 30 days. We have been doing a lot of training this week to make sure it’s going to get fixed. I think it’s just the newer roles that are still learning.” The surveyor asked who was ultimately responsible for assuring the OASIS is transmitted to CMS within 30 days. The Administrator stated, “I am that’s. That’s why we have been doing the training to make sure it is corrected.” On 06/28/2024 at approximately 1:30 PM, the surveyor reviewed the preliminary findings with the Administrator. The agency did not dispute the findings and did not provide any additional evidence to explain or correct the findings. Review of Agency policy titled, “SHH.038 ENCODING AND REPORTING OASIS DATA” “Effective Date: 9/09/2020” read in part: “… 3. Procedures: 1. Elara Caring will submit individual client assessment data within thirty (30) days of completing the comprehensive assessment. WHEN THE DATA IS LOCKED, IT IS TRANSMITTED TO THE IQIES SYSTEM. This is to be done within 30 days of the day the OASIS was completed…”

A Recertification survey with follow-up to survey from 06/29/2018 and a complaint. An entrance conference was conducted on 06/10/2021 with the Area Vice President of Skilled Services and via phone with the Administrator at 10:00 a.m. Census: Dallas (parent) Licensed and Certified - 134 Licensed Home Health - 0 Arlington (branch) Licensed and Certified - 12 Licensed Home Health - 0 Agency Total Census: 146 An exit conference was conducted on 06/18/2021 with the Administrator and Area Vice President of Skilled Services at 2:00 p.m. The preliminary findings were discussed. The complaint was fount to belong to a different licenses agency. The agency was in compliance with 42 Code of Federal Regulations Part 484, Conditions of Participation requirements for Home and Community Support Services Agencies related to Emergency Preparedness. HHSC - Health and Human Services Commission hha - Home Health Aide POC-Plan of Care SOC-Start of Care

A Recertification survey with follow-up to survey from 06/29/2018 and a complaint. An entrance conference was conducted on 06/10/2021 with the Area Vice President of Skilled Services and via phone with the Administrator at 10:00 a.m. Census: Dallas (parent) Licensed and Certified - 134 Licensed Home Health - 0 Arlington (branch) Licensed and Certified - 12 Licensed Home Health - 0 Agency Total Census: 146 An exit conference was conducted on 06/18/2021 with the Administrator and Area Vice President of Skilled Services at 2:00 p.m. The preliminary findings were discussed. The complaint was fount to belong to a different licenses agency. The agency was provided with directions for writing an acceptable plan of correction. The agency was in compliance with 42 Code of Federal Regulations Part 484, Conditions of Participation requirements for Home and Community Support Services Agencies. HHSC - Health and Human Services Commission hha - Home Health Aide POC-Plan of Care SOC-Start of Care

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: This is a continuing violation cited on 06/29/2018 at G614 Based on record review and interviews, the agency failed to provide the patient and/or caregiver with written information out lining a visit schedule including frequency of visits by home health staff. In 7 (Patients #5, #6, #10, #11, #12, #13, and #14) of 7 patient home folders reviewed during a home visit, the agency failed to provide a written visit schedule to the patients. This failure placed the patients at risk of missed visits by staff when visits were not scheduled and conflicted with other appointments and the availably of the patients. Findings Include: Patient #5: Patient #5's clinical record contained a Plan of Care dated 2/24/21 to 4/24/21. The Plan of Care indicated that Patient #5 started on the agency's services on 8/28/20. The Plan of Care contained an order for Patient #5 to receive skilled nursing visits one time a week for one week, one time every other week for 6 weeks and one time a week for one week. The surveyor conducted a home visit to Patient #5 on 6/17/21 at 10:45 a.m. The surveyor asked Patient #5 how Patient #5 if anyone with the agency provided a written schedule of when visits would be made. Patient #5 responded, "No, they text my daughter" The surveyor reviewed Patient #5's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #5 said, "No." Patient #:6 Patient #6's clinical record contained a Plan of Care dated 3/11/21 to 5/09/21. The Plan of Care indicated that Patient #6 started on the agency's services on 3/11/21. The Plan of Care contained an order for Patient #6 to receive skilled nursing visits one time a week for four weeks, one time every other week for four weeks, and one time a week for one week. The surveyor conducted a home visit to Patient #6 on 6/17/21 at 10:00 a.m. The surveyor asked Patient #6 if anyone had provided Patient #6 anything in writing of when the nurse or therapist would be making visits. Patient #6 responded, "No, she (the nurse) texts me and comes between 2 and 3 and I don't have therapy anymore. The surveyor reviewed Patient #6's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #6 said, "No." Patient #10: Patient #10's clinical record contained a Plan of Care dated 4/20/21 to 6/18/21. The Plan of Care indicated that the Patient #10 was admitted to the agency's services on 2/19/21. The Plan of Care contained orders for Patient #10 to received skilled nursing visits once a week for two weeks, one time every other week for six weeks and one time a week for one week. The surveyor conducted a home visit to Patient #10 on 3/17/21 at 9:00 a.m. The surveyor asked Patient #10 did Patient #10 get anything in writing of when the nurse would be coming for visits. Patient #10 stated, "No, they just call me." The surveyor reviewed Patient #10's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #10 said, "No." Patient #11: Patient #11's clinical record contained a Plan of Care dated 4/21/21 to 6/19/21. The Plan of Care indicated that the Patient #11 was admitted to the agency's services on 2/20/21. The Plan of Care contained orders for Patient #11 to received skilled nursing visits once a week for three weeks, two times a week for one week, one time a week for two weeks one time every other week, and one time a week for one week. The surveyor conducted a home visit to Patient #11 on 6/17/21 at 12:00 p.m. The surveyor asked Patient #11 did Patient #11 get anything in writing of when the nurse or therapist would be coming for visits. Patient #11's daughter stated, "No, they text me." The surveyor reviewed Patient #11's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #11 said, "Not that I am aware of." Patient #12: Patient #12's clinical record contained a Plan of Care dated 4/15/21 to 6/13/21. The Plan of Care indicated that the Patient #12 was admitted to the agency's services on 4/15/21. The Plan of Care contained orders for Patient #12 to received skilled nursing visits once a week for four weeks, one time every other week for four weeks and one time a week for one week; physical therapy visits were ordered one time a week for one week and two times a week for four weeks; occupational therapy were ordered three times a week for one week and 2 times for three weeks. The surveyor conducted a home visit to Patient #12 on 6/17/21 at 1:00 p.m. The surveyor asked Patient #12 did Patient #12 get anything in writing of when the nurse and therapists would be coming for visits. Patient #12 stated, "No, they tell me at the last visit and then call me the day before." The surveyor reviewed Patient #12's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #12 said, "No." Patient #13: Patient #13's clinical record contained a Plan of Care dated 5/22/21 to 7/20/21. The Plan of Care indicated that the Patient #13 was admitted to the agency's services on 5/22/21. The Plan of Care contained orders for Patient #13 to received skilled nursing visits one time a week for one week, three times a week for three weeks, one time a week for five weeks; physical therapy was ordered one time a week for one week. The surveyor conducted a home visit to Patient #13 on 6/18/21 at 10:05 a.m. The surveyor asked Patient #13 did Patient #13 get anything in writing of when the nurse would be coming for visits. Patient #13 stated, "No, they text or call me." The surveyor reviewed Patient #13's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #13 said, "No." Patient #14: Patient #14's clinical record contained a Plan of Care dated 6/07/21 to 8/05/21. The Plan of Care indicated that the Patient #14 was admitted to the agency's services on 6/07/21. The Plan of Care contained orders for Patient #14 to received skilled nursing visits one time a week for three weeks, one time every other week for 6 weeks: physical therapy was ordered two times a week for 3 weeks; occupational therapy was ordered three times a week for one week, two times a week for seven weeks and one time a week for one week; home health aide was ordered two times a week for three weeks. The surveyor conducted a home visit to Patient #14 on 6/18/21 at 10:45 a.m. The surveyor asked Patient #14 did Patient #14 get anything in writing of when the nurse would be coming for visits. Patient #14 stated, "No, not per say, we would like to have a calendar but being short staffed and all the nurse says Wednesday or Thursday, they all call or text the night before." The surveyor reviewed Patient #14's home folder. There was no evidence of a written schedule of visits found in the folder. The surveyor asked if anything had been removed from the folder. Patient #14 said, "No." During an interview on 6/18/21 at approximately 1:05 p.m. with the Administrator, Employee A the surveyor reviewed the home visit finding of 7 of 7 home visits there was no evidence in the patient's (#5, #6, #10, #11, #12, #13, and #14) home folder of a written schedule of visits. When the patients were questioned about a written schedule of visits all answered no, they either received calls or text the day before or day of the visits by the clinicians. The Administrator said, "The nurses have the ability to do that, it's hard to say exactly what days the patients will be seen." The Administrator did not dispute the findings.

Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This ELEMENT is not met as evidenced by: This is a continuing violation cited on 06/29/18 at G716 Based on record review and interview, the nurses and therapists failed to ensure clinical and progress notes were written prepared as required in 7 (Patients #1, #2, #3, #4, #7, #9, #10) of 12 active records reviewed. This failure placed the agency patients at risk of not receiving the appropriate care and services. Findings include: Patient #1: The record contained a plan of care with a start of care date of 4/05/21 for the treatment period of 4/05/21 to 6/03/21. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 4/05/21. The POC contained physician orders for the skilled nurse to visit one time a week for nine weeks; home health aide visits ordered one time a week for four weeks; physical therapy visits ordered two times a week for six weeks; and occupational therapy visits ordered one time a week for one week and two times a week for four weeks. The POC included the diagnosis of; "type 2 diabetes mellitus without complications" and the following other diagnoses; "mild intermittent asthma with (acute) exacerbation, weakness, metabolic syndrome, hydrocephalus in diseases classified elsewhere, Major depressive disorder, recurrent, in full remission and hypothyroidism, unspecified." Further review of the electronic medical record for active Patient #1 included 5 skilled nursing "Visit Note Reports", 2 home health "Visit Note Reports" and 4 occupational therapy "Visit Note Reports" that were not documented the day the visits were made as follows: Date of visit date completed signed by Skilled Nursing 4/13/21 4/14/21 Registered Nurse, Employee C Skilled Nursing 4/20/21 4/22/21 Registered Nurse, Employee C Skilled Nursing 4/30/21 5/06/21 Licensed Vocational Nurse, Employee G Skilled Nursing 5/06/21 5/11/21 Licensed Vocational Nurse, Employee G Skilled Nursing 5/11/21 5/17/21 Licensed Vocational Nurse, Employee G Skilled Nursing 5/18/21 5/21/21 Registered Nurse, Employee C Home Health Aide 4/13/21 4/14/21 Registered Nurse, Employee C Home Health Aide 4/20/21 4/22/21 Registered Nurse, Employee C Occupational therapy 4/16/21 4/18/21 Occupational Therapist, Employee L Occupational therapy 4/21/21 4/22/21 Occupational Therapist, Employee L Occupational therapy 5/14/21 5/15/21 Occupational Therapist, Employee L Occupational therapy 5/19/21 5/21/21 Occupational Therapist, Employee L The clinicians failed to write their notes the day the services were rendered. Patient #2: The record contained a plan of care with a start of care date of 4/09/21 for the treatment period of 4/09/21 to 6/07/21. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 4/09/21. The POC contained physician orders for the skilled nurse to visit one time a week for four weeks, one time every other week for four weeks and one time a week for one week; home health aide visits ordered one time a week for one week and two times a week for one week; physical therapy visits ordered two times a week for five weeks; occupational therapy visits ordered three times a week for one week and 2 times a week for three weeks; and medical social worker visit ordered one time a week for one week. The POC included the diagnosis of; "chronic obstructive pulmonary disease, anxiety disorder, major depressive disorder, chronic pain syndrome, low back pain, essential primary hypertension, unspecified osteoarthritis, with dependence on supplemental oxygen and personal history of malignant neoplasm of cervix." Further review of the electronic medical record for active Patient #2 included 3 skilled nursing "Visit Note Reports" that were not documented the day the visits were made as follows: Date of visit date completed signed by Skilled Nursing 4/16/21 4/21/21 Licensed Vocational Nurse, Employee G Skilled Nursing 5/13/21 5/20/21 Licensed Vocational Nurse, Employee G Skilled Nursing 5/25/21 5/27/21 Licensed Vocational Nurse, Employee G The clinician failed to write the notes the day the services were rendered. Patient #3: The record contained a plan of care with a start of care date of 3/13/21 for the treatment period of 3/13/21 to 5/11/21. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 3/13/21. The POC contained physician orders for the skilled nurse to visit one time a week for four weeks, one time every other week for four weeks and one time a week for one week; physical therapy visits ordered one time a week for one week, two times a week for four weeks; and occupational therapy visits ordered two times a week for one week. The POC included the diagnosis of; "wedge compression fracture first and second lumber vertebrae, essential hypertension, mixed hyperlipidemia, schizoaffective disorder, bipolar type, bipolar disorder hypothyroidism, generalized anxiety disorder." Further review of the electronic medical record for active Patient #3 included 6 skilled nursing "Visit Note Reports" that were not documented the day the visits were made as follows: Date of visit date completed signed by Skilled Nursing 3/19/21 3/22/21 Licensed Vocational Nurse, Employee H Skilled Nursing 3/22/21 3/25/21 Licensed Vocational Nurse, Employee H Skilled Nursing 3/29/21 4/01/21 Licensed Vocational Nurse, Employee H Skilled Nursing 4/08/21 4/16/21 Licensed Vocational Nurse, Employee G Skilled Nursing 4/16/21 4/19/21 Registered Nurse, Employee D Skilled Nursing 4/28/21 5/05/21 Licensed Vocational Nurse, Employee G The clinicians failed to write their notes the day the services were rendered. Patient #4: The record contained a plan of care with a start of care date of 2/02/21 for the treatment period of 4/03/21 to 6/01/21. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 4/01/21. The POC contained physician orders for the skilled nurse to visit one time a week for three weeks, one time every other week for four weeks and one time a week for one week; physical therapy visits ordered one time a week for one week; occupational therapy visits ordered two times a week for four weeks; and speech therapy visits ordered one time a week for three weeks. The POC included the diagnosis of; "hemiplegia, dysphagia, dysarthria, aphasia, hypertensive chronic kidney disease stage 5, anemia in chronic kidney disease, end stage renal disease." Further review of the electronic medical record for active Patient #4 included 4 skilled nursing "Visit Note Reports" that were not documented the day the visits were made as follows: Date of visit date completed signed by Skilled Nursing 4/07/21 4/15/21 Licensed Vocational Nurse, Employee H Skilled Nursing 4/14/21 4/16/21 Licensed Vocational Nurse, Employee H Skilled Nursing 5/07/21 5/09/21 Licensed Vocational Nurse, Employee I Skilled Nursing 5/21/21 5/23/21 Licensed Vocational Nurse, Employee I The clinicians failed to write their notes the day the services were rendered. Patient #7: The record contained a plan of care with a start of care date of 3/03/21 for the treatment period of 3/03/21 to 5/01/21. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 3/03/21. The POC contained physician orders for the skilled nurse to visit one time a week for one week, three times a week for one week, two times a week for two weeks and one time a week for one week; physical therapy visits one time a week for one week and two times a week for three weeks; occupational therapy visits ordered one time a week for one week. The POC included the diagnosis of; "encounter for surgical aftercare follow surgery on the digestive system, incisional hernia with obstruction, hypertensive chronic kidney disease stage 5, type 2 diabetes mellitus, end stage renal disease, hyperkalemia, morbid obesity, anxiety, chronic obstructive pulmonary disease." Further review of the electronic medical record for active Patient #7 included 3 skilled nursing "Visit Note Reports" that were not documented the day the visits were made as follows: Date of visit date completed signed by Skilled Nursing 3/13/21 3/15/21 Licensed Vocational Nurse, Employee F Skilled Nursing 4/17/21 4/25/21 Licensed Vocational Nurse, Employee F Skilled Nursing 4/23/21 4/25/21 Licensed Vocational Nurse, Employee F The clinician failed to write the notes the day the services were rendered. Patient #9: The record contained a plan of care with a start of care date of 2/22/21 for the treatment period of 2/22/21 to 4/22/21. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 2/22/21. The POC contained physician orders for the skilled nurse to visit two times a week for two weeks and one time a week for seven weeks; physical therapy visits ordered one time a week for one week and two times a week for four weeks; and occupational therapy visits ordered two times a week for one weeks. The POC included the diagnosis of; "Urinary tract infection, eschericia colias the cause of diseases classified elsewhere, encephalopathy, acidosis, hypertensive heart disease with heart failure, unspecified protein calorie malnutrition, hypothyroidism, dementia and bi-polar disorder." Further review of the electronic medical record for active Patient #9 included 5 skilled nursing "Visit Note Reports" and 4 physical therapy "Visit Note Reports" that were not documented the day the visits were made as follows: Date of visit date completed signed by Skilled Nursing 2/25/21 2/28/21 Licensed Vocational Nurse, Employee F Skilled Nursing 4/02/21 4/04/21 Licensed Vocational Nurse, Employee F Skilled Nursing 4/06/21 4/08/21 Licensed Vocational Nurse, Employee F Skilled Nursing 4/12/21 4/14/21 Licensed Vocational Nurse, Employee F Skilled Nursing 4/16/21 4/19/21 Licensed Vocational Nurse, Employee F Physical therapy 3/03/21 3/05/21 Physical Therapist, Employee K Physical therapy 3/05/21 3/09/21 Physical Therapist, Employee K Physical therapy 3/10/21 3/12/21 Physical Therapist, Employee K Physical therapy 3/17/21 3/18/21 Physical Therapist, Employee K The clinicians failed to write their notes the day the services were rendered. Patient #10: The record contained a plan of care with a start of care date of 2/19/21 for the treatment period of 4/20/21 to 6/18/21. The plan of care was electronically signed by the Alternate Administrator/Alternate Supervising Nurse on 4/15/21. The POC contained physician orders for the skilled nurse to visit one time a week for two weeks, one time every other week for six weeks and one time a week for one week. The POC included the diagnosis of; "atherosclerotic heart disease of native coronary artery, hypertensive heart and chronic kidney disease with heart failure, chronic systolic congestive heart failure, type 2 diabetes mellitus with hyperglycemia and chronic kidney disease, cardiomyopathy, morbid obesity, and hyperlipidemia." Further review of the electronic medical record for active Patient #10 included 2 skilled nursing "Visit Note Reports" that were not documented the day the visits were made as follows: Date of visit date completed signed by Skilled Nursing 4/22/21 4/25/21 Licensed Vocational Nurse, Employee F Skilled Nursing 6/11/21 6/12/21 Licensed Vocational Nurse, Employee F The clinician failed to write the notes the day the services were rendered. During an interview with the Administrator/Supervising Nurse, Employee A on 6/14/21 at approximately 2:47 p.m. the surveyor asked the Administrator what the agency policy was on documentation of visit notes related to timelines. The Administrator said the same day and turned in within 24 hours. The Administrator went on to say that if insurance approval is pending the note may not be input for the clinician to document the visit until approval is received. During an interview with Registered Nurse, Employee C on 6/16/21 at approximately 4:23 p.m. the surveyor reviewed the above finding on visit notes not documented the day the services are rendered for Patient #1. Employee C said that she always documents her visit notes by the next morning and within 24 hours. During an interview with Licensed Vocational Nurse, Employee G on 6/16/21 at approximately 4:39 p.m. the surveyor reviewed the above findings on Employee G's visit notes not documented the day the services are rendered for Patient #1, Patient #2, and Patient #3. Employee G said she does them the next morning. During an interview with Licensed Vocation Nurse, Employee F on 6/16/21 at approximately 5:09 p.m. the surveyor reviewed the above findings on Employee F's visit notes for Patient #7, #9 and #10 not documented the day the visit was made. Employee said that the visits are not always scheduled to her yet so she could not document them as they are not on her devise. Employee F said that she documents them as soon as they are on my devise. Employee H called surveyor while interviewing Employee C on 6/16/21 at 4:28 p.m. and left a voice mail. Surveyor call Employee H at 4:42 p.m.-no answer-left message requesting a return call. No return call from Employee H received by end of survey. The agency did not dispute the findings. According to the Texas Administrative Code. Title 26, Part 1, Chapter 558: Licensing Standards for Home and Community Support Services Agencies, §558.301(a)(9)(D): Each client record must include the following elements as applicable to the scope of services provided by the agency: (D) clinical and progress notes. Such notes must be written the day service is rendered and incorporated into the client record within 14 working days; Agency Policy - C873 Clinical Documentation and Changes to the Medical Record read in part ..." Policy Medical records are legal documents that support the delivery of services ...Procedures ...4. Documentation shall be completed as soon as possible to meet clinical and operations standards, but no later than the state-defined timeframe ..."