Every finding on record at Recover Health of Iowa, Inc

Amended after IDR 7/31/24 As directed by the Centers for Medicare and Medicaid Services (CMS) Kansas City Location, the Department of Inspections, Appeals and Licensing conducted an unannounced complaint survey for complaint #104343-C & 103930-C from 2/12/24 to 2/15/24. The complaint survey identified the following: Condition of Participation 42 CFR 484.50 Patient Rights was investigated and no condition level deficiencies were identified and three standard level deficiencies were identified (G438, G468 and G470). Condition of Participation 42 CFR 484.60 Care Planning Coordination and Quality of Care was investigated and no condition level deficiencies were identified and one standard level deficiency was identified (G590). Condition of Participation 42 CFR 484.55 Comprehensive Assessment of Patients was investigated and no condition level deficiencies were identified. Condition of Participation 42 CFR 484.80 Home Health aide services was investigated and no condition level deficiencies were identified.

Patient rights CFR(s): 484.50 Condition of participation: Patient rights. The patient and representative (if any), have the right to be informed of the patient's rights in a language and manner the individual understands. The HHA must protect and promote the exercise of these rights. This CONDITION is not met as evidenced by: Based on surveyor observation, staff interview, record review and policy review the home health agency: 1) failed to ensure the patient had a confidential clinical record (G438) 2) failed to address the discharge for cause (G462) 3) failed to make efforts to resolve the problem (G466) 4) failed to provide contact information for other services available (G468) 5) failed to document efforts to resolve problems (G470) The cumulative effects of these systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 143 current patients.

Have a confidential clinical record CFR(s): 484.50(c)(6) Have a confidential clinical record. Access to or release of patient information and clinical records is permitted in accordance with 45 CFR parts 160 and 164. This ELEMENT is not met as evidenced by: Based on agency staff interview and patient/caregiver interview, policy review, clinical record review and review of other applicable documents, the agency failed to honor patient rights to have a confidential record for 1 of 3 sampled patients who had intakes with no admission to home health care. (Patient #8). Failure to allow patients to have a confidential clinical record resulted in violation of the patient's rights as allowed by agency policy, home health regulation and governing laws. Findings include: The agency policy, titled Patient Rights and Responsibilities, revised 1/23/23, stated all patients/clients will be informed of their rights and responsibilities in a language and manner that the individual understands including those with limited English proficiency and accessible to individuals with disabilities free of charge. The patient receives written information about rights and responsibilities during the initial evaluation visit, in advance of furnishing care to the patient and in accordance to law and regulation. A handout summarizing patient rights and responsibilities will be reviewed and given to all patient/families upon admission. Patient #8 had an intake date of 12/7/23 for possible admission for home health care services. Clinical record review included the following: The admission paperwork, dated 12/7/23, included electronic documentation the patient consented for pictures. The client coordination note report, dated 12/7/23, included documentation the nurse went to the patient's home and reviewed the policies, rules and patient's expectations with the patient. The patient agreed and signed the paperwork. The nurse completed the assessment and reviewed the patient's medications. A family member entered the home and demanded the nurse leave the home. The nurse left the home and the Clinical Manager was notified. During an interview on 2/13/24 at 2:00 PM, the patients' family member stated he/she came into the home and found Staff D, Registered Nurse (RN) in the patient's room taking pictures on her own personal cell phone. Staff D stated the pictures were to make the medication list. The family member told her to leave the patient's room and their home and did not wish to have services provided. During an interview on 2/14/24 at 11:00 AM the Administrator stated Staff D, RN was assigned to complete the admission for patient #8. Staff D went to patient #8's home for the admission and identified a person, identified as a family member, entered the home after the admission process had started. Staff D was asked by the family member to leave the home. Staff D admitted she took pictures of the patient's medications using her personal cell phone and had verbal permission from the patient. The Administrator further stated staff are not allowed to use their personal cell phone but are only to use their agency provided tablet to take pictures for security reasons. During an interview on 2/14/23 at 8:30 AM, Staff D, RN stated she received a referral from the Veterans Administration (VA) on 12/6/23 and made an appointment with the patient for 12/7/23. She stated she reviewed the policy book and he/she signed the paperwork. She asked him/her where the medications were and he/she showed her the medication/medication bottles were in the patient's bedroom. She stated she asked the patient if she could take pictures of the medications and he/she said yes. She took pictures with her personal cell phone to reconcile with the VA at a later time and did not use the agency provided tablet. The patient's brother came into the home and asked what she was doing. The patient's brother stated they did not want the service and asked her to leave their home. She identified the pictures were deleted off her personal cell phone after the visit due to the patient not admitted for services. She stated she had not been aware she could not take pictures with her personal cell phone but only with the agency provided secure tablet. She further stated education had been provided and she knew to only take pictures with the agency provided secure tablet. During an interview on 2/15/24 at 9:40 AM Patient #8, stated he/she saw the nurse taking pictures in his/her room. It bothered him/her a little bit and he/she wondered what was going on. He/she stated verbal permission was not given to take pictures in the home and he/she did not put permission in writing. The above findings were reviewed with the Administrator.

Before discharge for cause HHA must: CFR(s): 484.50(d)(5) The HHA determines, under a policy set by the HHA for the purpose of addressing discharge for cause that meets the requirements of paragraphs (d)(5)(i) through (d)(5)(iii) of this section, that the patient's (or other persons in the patient's home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the HHA to operate effectively is seriously impaired. The HHA must do the following before it discharges a patient for cause: This ELEMENT is not met as evidenced by: Based on staff interview, patient/caregiver interview, agency policy review and clinical record review, the agency failed to document the patient's behaviors and circumstances that warranted patient's discharge for cause and the agency's efforts to resolve the problems prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #6) Failure to document the patient's behaviors and circumstances that warranted the patient's discharge prevented the patient from attempting to correct the issue prior to the involuntary discharge. Findings include: According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company's policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. During an interview on 2/13/24 at 3:34 PM Staff C, Home Care Aide (HCA) stated she called the patient and the patient told her the Doctor wanted him/her to go to the Emergency Room. She stated she did not need a bath aide. Staff C offered services on another day and the patient said he/she did not need a bath aide. Staff C notified the Case Manager, Patient #6 did not want aide services. During an interview on 2/14/24 at 3:40 PM with Patient #6, the patient stated he/she had not been aware the agency was going to discharge him/her. He/she stated he/she had no aide service provided to him/her in the home and denied refusing aide services from the agency. During an interview on 2/14/23 at 8:30 AM, Staff E, RN stated Patient #6 called the on call service for clean up after soiling him/herself. Staff E explained to the patient the services the agency provided for patients and that staff could not go and assist the patient at any time. The patient was not satisfied and wanted more services. She could not recall anything regarding the patient refusing home health aide services. Staff E stated she told the patient she could go with other agencies and companies for services but didn't have a name or contact information to give the patient. Staff E reported she did not know if she documented the conversations. During an interview on 2/14/24 at 4:20 PM with Staff B, Clinical Manager, she stated the care team had concerns about Patient #6's safety in his/her home. She stated she called the patient's Doctor and communicated the patient refused aide services and multiple falls in the home and called EMT services several times and had a wound on his/her bottom. The Doctor said the patient should go to the Emergency Room and if the agency thought it was not safe for the patient in the home, we could discharge him/her. She further expressed concerns for safety due to falls and wounds. She informed Patient #6, the Doctor requested for Patient #6 to go to the Emergency Room and concerns for safety due to falls and wound and the agency was going to discharge him/her from services. The patient did not agree with discharge and stated his/her roommate was not willing to help him/her. Interview on 2/15/24 at 9:12 AM with the patient's primary physician, revealed on 10/19/23, he had a phone message from the agency the patient had declined, refused a skin assessment and the agency was not available to provide 24/7 care for him/her. He stated the agency filed a report with the Department of Health and Human Services (DHHS) feeling she was not safe in the home. The doctor explained the patient was strong willed and will let people know how it was going to work. The agency felt she needed a higher level of care. On 10/23/23 the patient missed a visit at his office. They were trying to get her into a higher level of care and he did recommend it. He stated he didn’t know if the agency attempted to find other facilities but it would have been hard to find another provider to provide services in the home. Patient #6 had a start of care date of 10/4/23 and was discharged by the agency on 10/23/23. Clinical record review and associated patient and staff interviews included the following: a. The Plan of Care (POC), dated 10/4/23-12/4/23, included physician orders for skilled nursing services one time a week, physical therapy services two times a week, occupational therapy services one time a week and effective 10/15/23 home health aide services one time a week. b. The care coordination note, dated 10/13/23, included a call to the doctor's office at 12:00 PM to report the patient had fallen two times within the last two days without any injuries. They also reported occupational therapy reported a blood pressure of 122/45 without symptoms. c. The care coordination note, dated 10/17/23, documented a call to physician to report the patient was not safe in the home. The Doctor recommended the patient should go to the emergency room. d. The care coordination note, dated 10/17/23, documented the occupational therapist reported patient reported two falls since last week. They discussed with PTA, PT and nurse concerns and recommended skilled nursing facility. e. The care coordination note, dated 10/19/23, documented concerns for the patient being safe at home with collaboration from the home health agency care team. On admission the patient originally refused to allow nursing to complete a full skin assessment. Last week (week of 10/13/23) he/she had to have emergency medical services come to his/her home up to four times due to falling or slipping out of the chair and needing assistance with changing position in his/her chair. It is taking three people with maximum effort to move/position in the chair. He/she is unable to get to the bathroom and is sitting in his/her urine and feces. The physical therapy assistant assisted with changing the pad and noticed multiple pressure ulcers and some blood noted on the pad. Concerns for patient safety at home and self neglect. DHS report has been filed. Over the weekend the patient called and stated he/she had soiled his/herself and needed someone to come clean him/her up. Physician notified of home health agency concerns of patient safety. Spoke with patient about staff concerns about safety in the home. Expressed to patient that clinicians are concerned about his/her safety and do not feel he/she is safe, so will be unable to continue providing services. Doctor aware and agrees to discharge and patient should go to emergency room to get further assistance. f. The episode summary report (discharge summary), dated 10/23/24, documented the patient discharge to home or self care due to skilled services exceed what can safely be provided in home setting. She/He is dependent upon self care. The patient had falls and called EMT several times to help him/her get up and also called on weekends to ask if someone can go to him/her after had a bowel movement due to unable to clean self. The clinical record lacked documentation of the patient's received contact notification of agencies who may have the ability to provide care prior to the patients' discharge. The above findings were reviewed with the agency Administrator.

Make efforts to resolve the problem(s) CFR(s): 484.50(d)(5)(ii) (ii) Make efforts to resolve the problem(s) presented by the patient's behavior, the behavior of other persons in the patient's home, or situation; This ELEMENT is not met as evidenced by: Based on agency staff interview, patient/caregiver interview, agency policy review and clinical record review, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #6). Failure to attempt to initiate any efforts to resolve problems denied the patient the ability to attempt to correct the issue prior to the involuntary discharge. Findings Include: According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company's policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. Patient #6 had a start of care date of 10/16/2020 and was discharged by the agency for cause on 10/23/2023. See G0462 for additional information. The agency failed to attempt to resolve the issues prior to discharge. The above findings for Patient #6 were reviewed with the agency Administrator.

Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This ELEMENT is not met as evidenced by: Based on agency staff interview, patient/caregiver interview, agency policy review and clinical record review, the agency failed to provide contact information for other agencies or providers who may be able to provide care prior to discharging the patient for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patient #6) Failure to provide contact information of other providers hindered the patient ability to attempt to contact other agencies or providers to assist prior to the involuntary discharge. Findings include: According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company's policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. During an interview on 2/13/24 at 3:34 PM Staff C, Home Care Aide (HCA) stated she called the patient and the patient told her the Doctor wanted him/her to go to the Emergency Room. She stated she did not need a bath aide. Staff C offered services on another day and the patient said he/she did not need a bath aide. Staff C notified the Case Manager, Patient #6 did not want aide services. During an interview on 2/14/24 at 3:40 PM with Patient #6, the patient stated he/she had not been aware the agency was going to discharge him/her. He/she stated he/she had no aide service provided to him/her in the home and denied refusing aide services from the agency. During an interview on 2/14/23 at 8:30 AM, Staff E, RN stated Patient #6 called the on call service for clean up after soiling him/herself. Staff E explained to the patient the services the agency provided for patients and that staff could not go and assist the patient at any time. The patient was not satisfied and wanted more services. She could not recall anything regarding the patient refusing home health aide services. Staff E stated she told the patient she could go with other agencies and companies for services but didn't have a name or contact information to give the patient. Staff E reported she did not know if she documented the conversations. During an interview on 2/14/24 at 4:20 PM with Staff B, Clinical Manager, she stated the care team had concerns about Patient #6's safety in his/her home. She stated she called the patient's Doctor and communicated the patient refused aide services and multiple falls in the home and called EMT services several times and had a wound on his/her bottom. The Doctor said the patient should go to the Emergency Room and if the agency thought it was not safe for the patient in the home, we could discharge him/her. She further expressed concerns for safety due to falls and wounds. She informed Patient #6, the Doctor requested for Patient #6 to go to the Emergency Room and concerns for safety due to falls and wound and the agency was going to discharge him/her from services. The patient did not agree with discharge and stated his/her roommate was not willing to help him/her. Interview on 2/15/24 at 9:12 AM with the patient's primary physician, revealed on 10/19/23, he had a phone message from the agency the patient had declined, refused a skin assessment and the agency was not available to provide 24/7 care for him/her. He stated the agency filed a report with the Department of Health and Human Services (DHHS) feeling she was not safe in the home. The doctor explained the patient was strong willed and will let people know how it was going to work. The agency felt she needed a higher level of care. On 10/23/23 the patient missed a visit at his office. They were trying to get her into a higher level of care and he did recommend it. He stated he didn’t know if the agency attempted to find other facilities but it would have been hard to find another provider to provide services in the home. Patient #6 had a start of care date of 10/4/23 and was discharged by the agency on 10/23/23. Clinical record review included the following: a. The Plan of Care (POC), dated 10/4/23-12/4/23, included physician orders for skilled nursing services one time a week, physical therapy services two times a week, occupational therapy services one time a week and effective 10/15/23 home health aide services one time a week. b. The care coordination note, dated 10/13/23, included a call to the doctor's office at 12:00 PM to report the patient had fallen two times within the last two days without any injuries. They also reported occupational therapy reported a blood pressure of 122/45 without symptoms. c. The care coordination note, dated 10/17/23, documented a call to physician to report the patient was not safe in the home. The Doctor recommended the patient should go to the emergency room. d. The care coordination note, dated 10/17/23, documented the occupational therapist reported patient reported two falls since last week. They discussed with PTA, PT and nurse concerns and recommended skilled nursing facility. e. The care coordination note, dated 10/19/23, documented concerns for the patient being safe at home with collaboration from the home health agency care team. On admission the patient originally refused to allow nursing to complete a full skin assessment. Last week (week of 10/13/23) he/she had to have emergency medical services come to his/her home up to four times due to falling or slipping out of the chair and needing assistance with changing position in his/her chair. It is taking three people with maximum effort to move/position in the chair. He/she is unable to get to the bathroom and is sitting in his/her urine and feces. The physical therapy assistant assisted with changing the pad and noticed multiple pressure ulcers and some blood noted on the pad. Concerns for patient safety at home and self neglect. DHS report has been filed. Over the weekend the patient called and stated he/she had soiled his/herself and needed someone to come clean him/her up. Physician notified of home health agency concerns of patient safety. Spoke with patient about staff concerns about safety in the home. Expressed to patient that clinicians are concerned about his/her safety and do not feel he/she is safe, so will be unable to continue providing services. Doctor aware and agrees to discharge and patient should go to emergency room to get further assistance. f. The episode summary report (discharge summary), dated 10/23/24, documented the patient discharge to home or self care due to skilled services exceed what can safely be provided in home setting. She/He is dependent upon self care. The patient had falls and called EMT several times to help him/her get up and also called on weekends to ask if someone can go to him/her after had a bowel movement due to unable to clean self. The agency failed to provide the patient with contact information for other agencies or providers. The above findings were reviewed with the agency Administrator.

Document efforts to resolve problems CFR(s): 484.50(d)(5)(iv) (iv) Document the problem(s) and efforts made to resolve the problem(s), and enter this documentation into its clinical records; This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review, agency staff interview and patient/caregiver interview, the agency failed to initiate any efforts to resolve problems presented by the patient's behavior or a situation prior to discharging the patient for cause for 1 of 1 sampled patients discharged for behaviors or non-compliance (Patients #6) Failure to document the problems and efforts to resolve problems denied the patient of the ability to attempt to correct the issue prior to the involuntary discharge. According to the agency policy titled Discharge, Transfer, Referral and Corresponding Summary, dated 12/13/23, the patient and representative has a right to be informed of the company's policies for transfer and discharge. The patient/family will be notified of, and involved in, upcoming transfer/referral or discharge plans upon admission or as early in the course of care as possible when appropriate. The following are considerations for discontinuation of service or transfer of care: The company determines a discharge for cause related to the patient (or the behavior of other persons in the home) behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the patient or the ability of the company to operate effectively is seriously impaired. Before discharge for cause the following will occur: The patient, representative and the physician(s) involved in care will be notified that a discharge for cause is being considered. Make efforts to resolve the problem(s), Provide the patient and representative (if any) with contact information for other agencies or providers who may be able to provide care and Document the problem(s0 and efforts made to resolve the problem(s) and enter this documentation into the clinical record. Pt #6 had an admission date of and discharge date of 10/23/23. See G0468. The agency failed to make attempts to resolve the problem. The above findings were reviewed with the agency Administrator.

Care planning, coordination, quality of care CFR(s): 484.60 Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice. This CONDITION is not met as evidenced by: Based on agency staff interview, clinical record review and agency policy review the agency: 1) failed to ensure staff promptly alert relevant physician of changes. (G590) The cumulative systemic practices resulted in the failure to ensure the organizational framework of the agency promoted and supported the coordination of safe and effective delivery of care to the agency's 143 patients.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on agency staff interview and patient/caregiver interview, agency policy review and clinical record review, agency staff interview the agency failed to report changes in patient clinical findings or changes in patient needs to the physician for 1 of 10 sampled patients (Patients #6). Failure to communicate the patient's status with the physician placed agency patients at risk for unidentified worsening of conditions, inappropriate treatments, or unmet home health care needs. Findings include: According to the agency policy titled Coordination of Care, dated 11/9/23, all providers of care are encouraged to maintain open communication to ensure their efforts effectively complement one another. All efforts should support and enhance patient care needs. Communication will be maintained through effective service coordination regarding changes in the patient's needs, services or care goals. When a situation occurs that requires action by another provider of services, it is the responsibility of the agency staff to contact the other provider to assure awareness of the situation. This contact should be documented in the patient's record. Patient #6 had a start of care date of 10/4/23. Clinical record review revealed the following: a. The Plan of Care, dated 10/4/23 to 12/2/23, included orders for skilled nursing, physical therapy and occupational therapy services. b. The occupational therapy (OT) visit note, dated 10/9/23, documented the patient reported feeling worse than last week, like his/her mobility was gradually getting worse and he/she had a fear of falling. The patient reported a pain scale rating of 3 (out of 0 to 10) with reported pain in the anal area and feet. c. The Client Coordination Note Report, dated 10/9/23, documented OT staff notified the nurse and physical therapy about the patient's bowel movement Patient #6 reported the bowel movement had about 1/2 cup of blood in it and his/her anal area hurt. He/she also reported feeling like walking was more difficult in the last week. d. The client coordination note report, dated 10/20/23, documented a call received from the client asking about a Hoyer sling delivered to his/her home. He/she asked if someone could come and educate him/her and complained that the transportable oxygen had not arrived yet. Staff advised the patient to call his/her physician and reach out to the company that delivered the supplies to inquire about this. During an interview on 2/14/24 at 8:30 AM Staff D, RN stated she did not recall notification from the patient or occupational therapy that Patient #6 had blood with any bowel movement. She also stated she did not notify the physician of the patient report of bleeding. During an interview with the physician on 2/15//24 at 9:12 AM he stated he did not receive notification from the agency about the blood loss report but did identify the patient had a history of hemorrhoids. During an interview on 2/15/24 at 10:00 AM, Staff G, Team Coordinator stated she received a phone call from Patient #6 on 10/20/23. The patient reported, she received a Hoyer sling and asked if she could have some assistance with it. Staff G stated she didn’t think it was an expectation for staff to run over to the patient's home and didn't understand the expectation the patient had for staff to be available all the time. She could not recall if she contacted the nurse or documented contacting the nurse but would normally contact a nurse for a request that came into the office from a patient. She further stated the patient had also been upset the portable oxygen was not delivered yet but staff did not know what the agency could do about the oxygen. During an interview on 2/14/24 at 1:06 PM the Administrator stated she had not been aware of the patient's reported blood loss. She would expect staff to notify the physician. Agency staff failed to notify the physician of reported patient changes in condition. The above findings were reviewed with the Administrator.

Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review, home visit observation and agency staff interview, the agency failed to ensure skilled professional staff involved in the patient's plan of care completed an ongoing interdisciplinary wound assessment as required by agency policy and expectation for 1 of 3 sampled patients with wounds (Patient #6). Failure to complete an ongoing interdisciplinary assessment of wounds placed patients at risk unidentified worsening of the wounds. Findings include: According to the agency policy, titled Wound Care management, dated 10/12/23, wound assessment and wound care can be completed by: Registered Nurses, Licensed Practical Nurses and Physical Therapists. Wounds are to be measured weekly, or as ordered by the physician, and for any significant change in wound condition. Patient #6 had a start of care date of 10/4/23 and date of discharge of 10/23/23. Clinical record review revealed: The Plan of Care, dated 10/4/23-12/2/24, included physician orders for skilled nursing services 1 time a week times 1, 2 times a week times 1 and 1 time a week times 7 weeks. a. The comprehensive assessment, dated 10/4/23, documented the patient refused a skin assessment. b. The occupational therapy note, dated 10/9/23, included documentation Patient #6 reported he/she had about 1/2 cup of blood with a bowel movement and the anal area hurt. The note included documentation the nurse was notified. c. The physical therapy assistant (PTA) note, dated 10/18/23, documented staff assisted the patient to stand and change the pad under the patient. A new pressure area was noted to the bottom of the gluteal cleft. Staff were not able to take a picture or measure the size due to the patient inability to stand for a period of time. The patient was advised to go the emergency room for treatment and advised the patient to go to a skilled nursing facility for higher level of care. During an interview on 2/14/24 at 8:30 AM, Staff D, Registered Nurse (RN) stated she did not recall a report to notify her Patient #6 had a wound on his/her bottom. She further stated she would normally check on the patient, ask about the sore and check it out. She would then call the doctor. She stated she would notify her supervisors and do an extra visit if needed to assess the wound. During an interview on 2/14/24 at 11:00 AM the Administrator stated if the nurse was made aware of a wound, the expectation for the nursed to assess the wound in 24 to 48 hours. During an interview on 2/14/24 at 11:20 AM, Staff F, PTA stated during a home visit, he did notice the patient had an active bleeding area from a wound. The patient's physician and agency administration was notified. The patient educated to go to the emergency room for evaluation. The agency nurses failed to follow established agency policy and assess patients wounds. The above findings were reviewed with the Administrator.

A complaint investigation for complaint #71043 was conducted by the Department of Inspections and Appeals from 7/18/22 to 7/20/22. The allegation related to 42 CFR 484.105 Organization and Administration of Services: was Unsubstantiated with no deficiencies. The allegation related to 42 CFR 484.75 Skilled Professional Services: was Unsubstantiated with no deficiencies. The allegation related to 42 CFR 484.60 Care Planning, Coordination, Quality of Care: was Unsubstantiated with unrelated deficiencies. The allegation related to 42 CFR 484.50 Patient Rights: was Unsubstantiated with no deficiencies. The survey investigation found the agency to have standard level deficiencies in the above mentioned Condition of Participation, but to be, overall, in substantial compliance with the Conditions of Participation. The agency reported a census of 124 patients at the time of the survey.

Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This STANDARD is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interviews, the agency failed to follow a Plan of Care established and periodically reviewed by a physician or notify the physician of the need to vary frequency of visits or inability to perform treatments/services as originally ordered on the Plan for Care for 7 of 8 sampled patients (Patients #1, #2, #3, #4, #5, #6 and #8). Failure to follow a Plan of Care established by a physician placed patients at risk of not receiving safe, individualized and consistent care designed to meet each patient's health care needs. 4. Patient #4 had a start of care date of 5/24/22 and received intermittent home health services. Clinical record review revealed: a. Plan of Care, dated 5/24/22 to 7/22/22, included physician orders for skilled nursing services three times for one week and one time every two weeks for two weeks. i. Skilled nursing visit note, dated 5/24/22, identified this as the only skilled nurse assessment completed for this week. The skilled nurse failed to complete three visits the week of 5/24/22 as ordered or to document an order indicating why the visits were not completed and the physician was not notified of the missed visits. b. Resumption of Care orders, dated 6/13/22, included orders for skilled nursing services three times a week for one week and one time a week for three weeks; and occupational therapy services one time a week for one week and two times every two weeks for two weeks. i. Resumption of Care comprehensive assessment completed by the skilled nurse, dated 6/13/22, identified only one skilled nursing visit completed for the week of 6/13/22. ii. No occupational theapy visits were completed for the week of 6/13/22. The clinical record lacked documentation why the skilled nurse did not complete three visits as ordered, why occupational therapy did not complete visits as ordered and why physician was not notified of missed visits. c. Resumption of Care comprehensive assessment visit, dated 6/27/22, included orders for skilled nursing services three times a week for one week and one time a week for three weeks; and home health aide services four times a week for one week and three times a week for three weeks. i. Resumption of Care comprehensive assessment completed by the skilled nurse, dated 6/27/22, identified only one skilled nursing visit completed for the week of 6/27/22. ii. Home health aide visits, dated 7/1/22, 7/6/22 and 7/8/22, identified two aide visits completed for the week of 7/3/22. iii. Home health aide coordination note, dated 7/7/22, included documentation the visit on 7/4/22 was missed due to the holiday. During an interview on 7/19/22 at 2:45 PM, the Administrator reported the missed visits are entered as coordination notes in the electronic medical record system, the clerical staff then fax the coordination notes to the physician to notify of the missed visits. During an interview on 7/19/22 at 4:23 PM, the Administrator reported the missed visit for the aide on 7/4/22 did not get faxed to the physician. Clerical staff did not realize it needed to be done for holiday missed visits as well as other missed visits. During an interview on 7/20/22 at 10:15 AM, Staff B, Clinical Manager, reported as needed visits are entered on the scheduling calendar during the first week of services, these will show up in the visit count for that specific discipline. The as needed visits are removed from the discipline orders prior to the plan of care being sent to the physician for signature. She reported that may not have happened for this particular patient. The clinical record lacked documentation why services were not provided as ordered and the physician was not notified of the missed visits. 5. Patient #5 had a start of care date of 2/26/22. The patient received intermittent home health services. Clinical record review revealed: a. Plan of Care, dated 4/27/22 to 6/25/22, included physician orders for skilled nursing services two times for one week and three times a week for eight weeks. b. Skilled nursing visit notes, dated 6/17/22, 6/22/22 and 6/29/22, identified skilled nurse assessments were completed on these dates. The skilled nurse failed to complete three visits the week of 6/19/22 as ordered or to document an order indicating why the visits were not completed and the physician notified of the missed visits. 6. Patient #6 had a start of care date of 4/21/22 and received intermittent home health services. Clinical record review revealed: a. Plans of Care, dated 4/21/22 to 6/19/22, included orders for home health aide services four times a week for eight weeks. b. Home health aide visit notes, dated 6/6, 6/8, 6/10, 6/13, 6/15, 6/17, 6/27, 6/29, 7/1, 7/11, 7/13 and 7/15/22, identified three aide visits completed for the weeks of 6/5, 6/12, 6/26 and 7/10/22. The clinical record lacked documentation of a fourth aide visit for the above weeks or an order for a missed visit and the physician was notified of the missed visits. c. Home health aide visit notes, dated 6/22/22 and 6/24/22, identified two aide visits made for the week of 6/19/22. Coordination note, dated 6/20/22, included documentation of a missed aide visit and the agency provided the fax sheet to verify the physician was notified of the missed aide visit. The clinical record lacked documentation of a fourth aide visit for the week or a missed visit and the physician notified. d. Home health aide visit notes, dated 6/1/22 and 6/3/22, identified two aide visits made for the week of 5/29/22. Coordination note, dated 5/31/22, included documentation of a missed aide visit but lacked documentation the physician was notified of the missed aide visit. The clinical record lacked documentation of a fourth aide visit for the week or a missed visit and the physician notified. e. Home health aide visit notes, dated 7/6/22 and 7/8/22, identified two aide visits made for the week of 7/3/22. Coordination note, dated 7/5/22, included documentation of a missed aide visit but lacked documentation the physician was notified of the missed aide visit. The clinical record lacked documentation of a fourth aide visit for the week or a missed visit and the physician notified. During an interview on 7/20/22 at 10:10 AM, Staff B, Clinical Manager, reported the patient received homemaking services one time a week, these visits are scheduled on the calendar in the electronic medical record as home care aide services but are coded as homemaking services. 7. Patient #8 had a start of care date of 9/10/21, a discharge date of 5/3/22 and received intermittent home health services. Clinical record review revealed: a. Plan of Care, dated 3/9/22 to 5/7/22, included orders for skilled nursing services weekly. b. Skilled nursing visits, dated 3/16/22 and 3/29/22, identified no skilled nursing visits completed the week of 3/20/22. The surveyor reviewed the above findings with the Agency Administrator and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey. Findings include: According to the agency policy titled Missed Services, dated 6/14/16, when scheduled services, visits or shifts are not provided for any reason, the appropriate notification should be completed and sent to the physician or other appropriate entity in a timely manner. A copy of the notification is placed in the patient's record to reflect the alteration of the plan of care. 1. Patient #1 had a start of care date of 6/21/21. The patient received private duty nursing services and had a diagnosis of Lymphoblastic Leukemia. Clinical record review and associated agency staff interviews revealed the following: a. The Plans of Care, dated 4/17/22 to 6/15/22 and 6/16/22 to 8/14/22, included physician orders for skilled nursing services 7 to 10 hours per day for 4 to 5 days per week. b. Skilled nursing notes for the week of 6/12/22 through 6/18/22, revealed no skilled nursing services provided. The Missed Services and Physician Notification Report, dated 7/8/22, documented for the week of 6/12/22 through 6/18/22 the physician notified of 2 days, 6/13/22 and 6/17/22, missed skilled nursing services. The document lacked notification of the remaining 2 days when services provided failed to meet the 7 hour per day minimum requirements. 2. Patient #2 had a start of care date of 6/28/21. The patient received private duty nursing services and had a diagnosis of Shaken infant syndrome. Clinical record review and associated agency staff interviews revealed the following: a. The Plans of Care, dated 4/17/22 to 6/9/22 and 6/10/22 to 8/8/22, included physician orders for skilled nursing services 8 to 10 hours per day for 4 to 6 days per week. b. Skilled nursing notes for the week of 6/6/22 through 6/10/22, included documentation of 1 days of skilled nursing services provided. Nursing service provided 8 hours on the dates of 6/8/22. The Missed Services and Physician Notification Report, dated 7/8/22, documented for the week of 6/6/22 through 6/10/22 the physician notified of all days, 6/6/22 through 6/10/22, missed skilled nursing services. 3. Patient #3 had a start of care date of 6/14/22. The patient received private duty nursing services and had a diagnosis of Downs syndrome. Clinical record review and associated agency staff interviews revealed the following: a. The Plans of Care, dated 6/14/22 to 8/12/22, included physician orders for skilled nursing services 8 to 12 hours per day for 4 to 7 days per week. b. Skilled nursing notes for the week of 6/14/22 through 6/18/22, included documentation of 1 day of skilled nursing services provided. Nursing service provided on the date of 6/14/22. The notes identified the patient received only 3 hours of service on 6/14/22. The patient lacked receiving the ordered number of hours (8 hours) per day the 4 days per week of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/8/22, lacked documentation for the week of 6/14/22 through 6/18/22 the physician notified of missed skilled nursing services. The document lacked notification of the 4 days when services provided failed to meet the 8 hour per day minimum requirements. c. Skilled nursing notes for the week of 6/19/22 through 6/24/22, included documentation of 3 days of skilled nursing services provided. Nursing service provided on the date of 6/21/22 for only 7 hours, 6/22/22 for 9 hours and 6/23/22 for 10 hours. The patient lacked receiving the ordered number of hours (8 hours) per day the 4 days per week of skilled nursing services as ordered on the Plan of Care. The Missed Services and Physician Notification Report, dated 7/6/22, lacked documented for the week of 6/19/22 through 6/24/22 the physician notified of missed skilled nursing services. The document lacked notification of the remaining 2 days when services provided failed to meet the 8 hour per day minimum requirements.

Plan of care must include the following CFR(s): 484.60(a)(2)(i-xvi) The individualized plan of care must include the following: (i) All pertinent diagnoses; (ii) The patient's mental, psychosocial, and cognitive status; (iii) The types of services, supplies, and equipment required; (iv) The frequency and duration of visits to be made; (v) Prognosis; (vi) Rehabilitation potential; (vii) Functional limitations; (viii) Activities permitted; (ix) Nutritional requirements; (x) All medications and treatments; (xi) Safety measures to protect against injury; (xii) A description of the patient's risk for emergency department visits and hospital re-admission, and all necessary interventions to address the underlying risk factors. (xiii) Patient and caregiver education and training to facilitate timely discharge; (xiv) Patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; (xv) Information related to any advanced directives; and (xvi) Any additional items the HHA or physician or allowed practitioner may choose to include. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care for 1 of 8 sampled patients (Patients #1). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. Findings include: According to the agency policy titled Physician Orders, dated10/13/21, the Plan of Care/Treatment must include the following as applicable: medications (including over the counter) and treatments to be administered or monitored, including name, dosage, frequency and route of administration. Patient #1 a pediatric patient, had a start of care date of 6/21/21. a. The plan of care (POC), dated 6/16/22 to 8/14/22, included medications ordered by the physician. b. The medication Bacitracin 500 unit/gram (gm) topical 1 application prn (as needed). The POC lacked the ordered frequency of the medication. c. The medication Diphenhydramine-Phenylephrine (Benadryl) 20 milliliters (ml) per G-tube prn itching or anxiety. The POC lacked the ordered frequency of the medication. d. Loperamide 15 ml prn diarrhea. The POC lacked the ordered frequency of the medication. e. Hydrocortisone Na Succinate (solu CORTEF) 50 MG per injection, prn stress dosing. The POC lacked the ordered route of injection of the medication. During an interview on 7/19/22 at 3:30 PM, Staff C, Clinical Manager stated she had gone over with nursing staff the expectation to include frequency of prn orders. The above findings were reviewed with the Administrator and Staff C, Clinical Manager. The agency provided no additional information prior to the end of the survey.

All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This ELEMENT is not met as evidenced by: Based on clinical record review, agency policy review and agency staff interview, the agency failed to update the Plan of Care with all new physician orders for 3 of 3 sampled patients with interim orders. (Patients #5, #7 and #8). Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. Findings include: According to agency policy, titled Client's Plan of Care, dated 12/18/17, all patient care orders including verbal orders must be recorded in the plan of care upon receipt. During an interview on 7/19/22 at 10:15 AM, Staff B, Clinical Manager, reported the updated plan of care should show on the orders screen in the electronic medical record after the interim physician order is entered. The office staff are able to view the updated plan of care report in the electronic medical record but this area does not flow to the tablets for field staff to view. Field staff would have to view the updated plan of care on the order screen in the tablet. 1. Patient #7 had a start of care date of 3/21/22, a discharge date of 5/18/22 and received intermittent home health services. Clinical record review revealed: a. The Plan of Care, dated 3/21/22 to 5/18/22, included orders for skilled nursing services one time a week for one week, two times a week for one week, and one time a week for seven weeks; physical therapy services two times a week for three weeks and one time a week for five weeks; and occupational therapy services one time a week for one week and two times a week for three weeks. b. Interim physician order, dated 3/28/22, included orders to change the dose of Eliquis medication. c. Interim physician order, dated 4/14/22, included orders for occupational therapy additional visits one time a week for three weeks. The clinical record lacked documentation of an updated plan of care. During an interview on 7/19/22 at 10:15 AM, Staff B, Clinical Manager, reviewed the clinical record and confirmed she was not seeing an updated plan of care on this patient. 2. Patient #5 had a start of care date of 2/26/22 and received intermittent home health services. Clinical record review revealed: a. The Plan of Care, dated 4/27/22 to 6/25/22, included orders for skilled nursing and home health aide services. b. Interim physician order, dated 4/27/22, included orders for skilled nurse to cleanse right heel with normal saline, pat dry, apply nickel size amount of santyl to necrotic tissue, cover with gauze, secure with ace wrap. Three times a week until healed. Apply calmoseptine to left buttocks stage 2 pressure area and cover with 4x4 mepilex dressing until healed. Using aseptic clean technique and change dressing three times a week and as needed. The clinical record lacked documentation of an updated plan of care. 3. Patient #8 had a start of care date of 9/10/21, a discharge date of 5/3/22 and received intermittent home health services. Clinical record review revealed: a. The Plan of Care, dated 3/9/22 to 5/7/22, included orders for skilled nursing and home health aide services. b. Interim physician order, dated 4/21/22, included orders for additional home health aide visit week of 4/17/22. c. Interim physician order, dated 4/27/22, included additional skilled nursing visit for 4/28/22. The clinical record lacked documentation of an updated plan of care. The above findings were reviewed with the Agency Administrator and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey.

Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This ELEMENT is not met as evidenced by: Based on agency policy review, clinical record review and agency staff interview, the agency failed to provide treatments or services as ordered by the physician and per the Plan of Care for 2 of 8 sampled patients (Patients #3 and #5). Failure to ensure staff follow physician orders for administration of treatments and services provided by agency staff placed agency patients at risk for inconsistent care/treatment and possible harm. 2. Patient #5 had a start of care date of 2/26/22 and received intermittent home health services. Clinical record review revealed: a. Plan of Care, dated 4/27/22 to 6/25/22, included orders for skilled nurse for insertion of 20 french catheter maintenance with catheter, 10 ml (milliliter) balloon, change every month and as needed dislodgement or stoppage, and obtain urine specimen as indicated. b. Skilled nursing visit notes, dated 6/1, 6/3, 6/6, 6/8, 6/10, 6/13, 6/15, 6/17, 6/22 and 6/29/22, lacked documentation catheter was changed during the month of June. During an interview on 7/20/22 at 11:10 AM, Staff B, Clinical Manager, reviewed the clinical record and reported to surveyor the catheter was changed in the physician office. Staff B requested physician office forward information to agency but unsure when that will arrive. The agency staff failed to follow orders in the plan of care, failed to document the reason why and notify the physician. The surveyor reviewed the above findings with the Agency Administrator and Staff B, Clinical Manager. The agency provided no additional information prior to the end of the survey. Review of the agency's policy, titled Physician Orders, dated 10/13/21, identified agency staff will provide care and services in accordance with physician orders. 1. Patient #3, a pediatric patient, had a start of care date of 6/14/21. Review of the clinical record revealed the following: The POC, dated 6/14/22 to 8/12/22, included physician orders for skilled nursing services 8 to 12 hours per day, 4 to 7 days per week. The POC included orders for the skilled nurse to assess the patient's gastrointestinal system every 1 hour and as needed to prevent failure or compromise and include all 4 quadrants of bowel sounds, whether the abdomen is flat, round, firm, distended or non-distended. The POC included orders for the skilled nurse to assess the patient's respiratory system every 1 hour and as needed and to include pulse oximeter readings (blood oxygen), lung sounds per auscultation, of respirations are even/uneven, labored/unlabored, respiratory rate and any retractions or nasal flaring and CPT vest daily and as needed. The POC included orders for the skilled nurse to assess the patient's cardiovascular system including heart rhythm, pulse, pulse rate and description, skin color and capillary refill times, skin color and any other signs/symptoms of cardiovascular distress or compromise. a. The skilled nursing visit note, dated 6/14/22, included documentation the nurse worked 12:30 PM to 3:30 PM. The nurse documented doing an initial assessment at 1:00 PM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note lacked documentation of any further gastrointestinal, respiratory or cardiovascular system assessment for the remainder of the shift or the CPT vest treatment. b. The skilled nursing visit note, dated 6/21/22, included documentation the nurse worked 5:00 AM to 3:10 PM. The nurse documented doing an initial assessment at 5:24 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note included documentation of pulse oximeter readings at 6:00 AM and 7:30 AM and heart rate and respiratory rate at 7:30 AM. The visit note lacked documentation of any further gastrointestinal, respiratory or cardiovascular system assessment for the remainder of the shift or the CPT vest treatment. c. The skilled nursing visit notes, dated 6/22/22, included documentation a nurse worked 5:00 AM to 4:15 PM. The nurse documented doing an initial assessment at 5:15 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note lacked documentation of any further gastrointestinal assessment for the remainder of the shift or the CPT vest treatment. d. The skilled nursing visit note, dated 6/23/22, included documentation the nurse worked 5:00 AM to 2:50 PM. The nurse documented doing an initial assessment at 5:15 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note lacked documentation of any further gastrointestinal system assessment for the remainder of the shift or the CPT vest treatment. e. The skilled nursing visit note, dated 6/27/22, included documentation the nurse worked 5:00 AM to 4:45 PM. The nurse documented doing an initial assessment at 5:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note lacked documentation of any further gastrointestinal system assessment for the remainder of the shift or the CPT vest treatment. f. The skilled nursing visit note, dated 6/28/22, included documentation the nurse worked 5:00 AM to 4:49 PM. The nurse documented doing an initial assessment at 5:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note lacked documentation of any further gastrointestinal system assessment for the remainder of the shift or the CPT vest treatment. g. The skilled nursing visit note, dated 6/29/22, included documentation the nurse worked 5:00 AM to 3:00 PM. The nurse documented doing an initial assessment at 5:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note lacked documentation of any further gastrointestinal system assessment for the remainder of the shift or the CPT vest treatment. h. The skilled nursing visit note, dated 7/11/22, included documentation the nurse worked 5:00 AM to 5:00 PM. The nurse documented doing an initial assessment at 5:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The note included documentation of the patient's heart rate, pulse oximeter and respirations every 2 hours and not every 1 hour as ordered The visit note lacked documentation of any further gastrointestinal system assessment for the remainder of the shift or the CPT vest treatment. i. The skilled nursing visit note, dated 7/12/22, included documentation the nurse worked 5:00 AM to 10:30 AM. The nurse documented doing an initial assessment at 5:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note lacked documentation of any further gastrointestinal system assessment for the remainder of the shift. j. The skilled nursing visit note, dated 7/13/22, included documentation the nurse worked 5:00 AM to 4:45 PM. The nurse documented doing an initial assessment at 5:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note included documentation of the patient's heart rate, pulse oximeter readings and respiration rate every 2 hours instead of every hour as ordered. The visit note lacked documentation of any further gastrointestinal, respiratory or cardiac system assessment for the remainder of the shift. k. The skilled nursing visit note, dated 7/14/22, included documentation the nurse worked 6:55 AM to 3:00 PM. The nurse documented doing an initial assessment at 7:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note included documentation of the patient's heart rate, pulse oximeter readings and respiration rate every 2 hours instead of every hour as ordered. The visit note lacked documentation of any further gastrointestinal, respiratory or cardiac system assessment for the remainder of the shift. l. The skilled nursing visit note, dated 7/15/22, included documentation the nurse worked 7:00 AM to 1:00 PM. The nurse documented doing an initial assessment at 7:00 AM of the patient's gastrointestinal system, respiratory and cardiovascular system. The visit note included documentation of the patient's heart rate, pulse oximeter readings and respiration rate every 2 hours instead of every hour as ordered. The visit note lacked documentation of any further gastrointestinal, respiratory or cardiac system assessment for the remainder of the shift. On 7/12/22 at 2:16 PM, during an interview, the Private Duty Nurse Supervisor thought there was a glitch in the computer system which caused documentation issues on 6/29/22. She reported the nurse should be documenting why if the nurse is unable to follow an order. During an interview on 7/19/22 at 3:30 PM, Staff C, Clinical Manager stated the patient did require hourly assessments and staff expected to document in the nurse visit note.