Every finding on record at St Francis Hospital

On 10/17/23 through 10/20/23, a recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs at St. Francis Home Health Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted on 10/17/2023 through 10/20/2023, by the Michigan Department of Licensing and Regulatory Affairs at: St. Francis Home Health Care 901 North Lincoln Rd. Escanaba, MI 49829 At the time of the survey, the agency did not operate any branch offices or subunits. The agency provided the following services: Skilled Nursing, Physical Therapy, Occupational Therapy, Medical Social Work, Registered Dietician, and Home Health Aide. Clinical records reviewed for this survey included: 4 active records with home visits, 3 active records without home visits, and 3 discharge records for a total of 10 records reviewed.

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment visit was conducted within 48 hours of referral for 1 (Patient #9) of 10 records reviewed, resulting in a delay in determining the immediate care and support needs for the patient. Findings include: P-9: This 95-year-old patient was admitted to the home health agency on 1/9/23 with the diagnosis of a non-traumatic chronic subdural hemorrhage (bleeding around the brain). During record review on 10/18/23, it was determined the referral to start home health services was dated 1/5/23 with the patient's discharge from the hospital being 1/6/23. Upon further review of the record, it was noted the start of care (SOC) was done by the physical therapist on 1/9/23 - more than 48 hours after the referral was written. A note on the referral stated that "Kris" at Menominee Health stated a 1/9/23 start was "fine", however, there were no additional physician orders to approve the delay in care. There was also no documented reason why the start of care was delayed. Findings were reviewed with and acknowledged by the Clinical Manager (Staff A) during an interview on 10/19/23 at 3:55 p.m.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide a complete comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset and exacerbations in 9 of 10 (Patient #s 1, 2, 3, 5, 6, 7, 8, 9 and 10) records reviewed resulting in incomplete clinical information to aid in determining the needs of the patient and determining progress towards goals. Findings include: P-5: The Start of Care (SOC) was dated 9/16/23. The Plan of Care (POC) identified diagnoses of Pneumonia, Hypertensive Heart and Chronic Kidney Disease, Diabetes Type 2 and Congestive Heart Failure. During record review on 10/18/23, it was noted that the SOC comprehensive assessment dated 9/16/23, documented under "Primary Diagnosis and Other Diagnoses", all 25 diagnoses were dated 9/16/23. No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-6: The Start of Care (SOC) was dated 6/22/23. The Plan of Care (POC) identified diagnoses of Dementia, Diabetes Type 2 and Hypertension. During record review on 10/18/23, it was noted that the SOC comprehensive assessment dated 6/22/23, documented under "Primary Diagnosis and Other Diagnoses", all 16 diagnoses were dated 9/16/23. No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. P-7: The Start of Care (SOC) was dated 7/10/23. The Plan of Care (POC) identified diagnoses of Emphysema, Pneumonia and Chronic Respiratory Failure. During record review on 10/18/23, it was noted that the SOC comprehensive assessment dated 7/10/23, documented under "Primary Diagnosis and Other Diagnoses", all 27 diagnoses were dated 9/16/23. No onset, prior treatments, outcomes, or history of how these diagnoses led to the need for home care were documented. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 10/19/23 at 3:00 pm. P-1: This 87-year-old was admitted to the agency on 9/26/23 with diagnoses which included open wounds to lower legs; venous insufficiency (leg veins which do not allow normal blood flow back to the heart); and heart failure. The medical record was reviewed on 10/18/23. During review of the start of care (SOC) comprehensive assessment dated 9/26/23, it was noted that 1 “Primary Diagnosis”; 5 “Other Diagnoses”; and 24 “Additional Reportable Diagnoses” all included the date of 9/26/23. It was unclear whether the date represented onset or exacerbation of the listed diagnoses. P-2: This 76-year-old was admitted to the agency on 7/26/23 with diagnoses which included Sepsis (infection in the blood stream); urinary tract infection; and type 2 diabetes. The medical record was reviewed on 10/19/23. During review of the SOC comprehensive assessment dated 7/26/23, it was noted that 1 “Primary Diagnosis”; 5 “Other Diagnoses”; and 9 “Additional Reportable Diagnoses” all included the date of 7/26/23. It was unclear whether the date represented onset or exacerbation of the listed diagnoses. P-3: This 64-year-old was admitted to the agency on 9/9/23 with diagnoses which included heart failure; pleural effusion (fluid in the space surrounding the lungs); and heart attack. The medical record was reviewed on 10/19/23. During review of the SOC comprehensive assessment dated 9/9/23, it was noted that 1 “Primary Diagnosis”; 5 “Other Diagnoses”; and 15 “Additional Reportable Diagnoses” all included the date of 9/9/23. It was unclear whether the date represented onset or exacerbation of the listed diagnoses. The above findings were reviewed with the Clinical Manager (Staff A) on 10/19/23 at 5:20 p.m. Staff A stated that the computer does not allow certain details to be added and agreed that all the patient’s diagnoses should not be entered as the same date. This finding was acknowledged during interview on 10/20/23 at 9 a.m. with Staff A and the Administrator (Staff B). P-8: This 53-year-old patient was admitted to the home health agency on 6/19/23 with the diagnoses of unspecified encephalopathy (disease of the brain), compartment syndrome in the right lower leg (a condition that causes extreme pain due to swelling of tissues) and a wound of the right lower leg due to a procedure performed for the compartment syndrome. During record review on 10/18/23, it was noted the start of care (SOC) dated 6/19/23 had 1 "Primary Diagnosis" (the wound), 5 "Other Diagnoses", and 14 "Reportable Diagnoses" dated 6/19/23. As a result, it was unclear whether the diagnoses listed were new onset or an exacerbation. No onset dates, previous treatments, current active issues or history of how these diagnoses lead to the need for home care services were documented. P-9: This 95-year-old patient was admitted to the home health agency on 1/9/23 with the diagnosis of a non-traumatic chronic subdural hemorrhage (bleeding around the brain). During record review on 10/18/23, it was noted the SOC dated 1/9/23 had 1 "Primary Diagnosis", 5 "Other Diagnoses", and 4 "Reportable Diagnoses" dated 1/9/23. As a result, it was unclear whether the diagnoses listed were new onset or an exacerbation. No onset dates, previous treatments, current active issues or history of how these diagnoses lead to the need for home care services were documented. P-10: This 84-year-old patient was admitted to the home health agency on 9/7/23 with the diagnoses of a pressure ulcer of the sacral (tailbone) region, acute kidney failure, and type II diabetes. During record review on 10/18/23, it was noted the SOC dated 9/7/23 had 1 "Primary Diagnosis", 5 "Other Diagnoses", and 25 "Reportable Diagnoses". The Primary Diagnosis was dated 9/5/23 and the remaining 30 diagnoses were dated 9/7/23. As a result, it was unclear whether the diagnoses listed were new onset or an exacerbation. No onset dates, previous treatments, current active issues or history of how these diagnoses lead to the need for home care services were documented. Findings were reviewed with and acknowledged by the Clinical Manager (Staff A) during an interview on 10/19/23 at 3:55 p.m.

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 record review and interview, it was determined that the agency failed to ensure the Plan of Care included objectively measurable and individualized goals in 4 of 10 records reviewed (Patient #s 2, 5, 6 and 7), resulting in a potential for failure to measure progress toward achievement of desired outcomes. Findings include: P-5: The Start of Care (SOC) was dated 9/16/23. The Plan of Care (POC) identified diagnoses of Pneumonia, Hypertensive Heart and Chronic Kidney Disease, Diabetes Type 2 and Congestive Heart Failure. During record review on 10/18/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient will demonstrate knowledge of Diabetes disease process, treatment goals, signs and symptoms to report and self-care management. Target date: within 6 weeks” Additionally, another goal stated, “Patient will manage the Heart Failure Education and demonstrate teachback competency.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-6: The Start of Care (SOC) was dated 6/22/23. The Plan of Care (POC) identified diagnoses of Dementia, Diabetes Type 2 and Hypertension. During record review on 10/18/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Caregiver will demonstrate effective self-care management including understanding of ordered medication regimen, signs and symptoms to report, and recommended follow up with physician.” Additionally, another goal stated, “Patient centered long-term goal increase strength and avoid falls” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-7: The Start of Care (SOC) was dated 7/10/23. The Plan of Care (POC) identified diagnoses of Emphysema, Pneumonia and Chronic Respiratory Failure. During record review on 10/18/23, it was noted that the goals within the POC were not measurable. For example, one goal stated, “Patient and Caregiver will demonstrate effective self-care management including understanding of ordered medication regimen, signs and symptoms to report, and recommended follow up with physician.” Additionally, another goal stated, “Patient centered long-term goal Patient and caregiver will be able to manage COPD will resolve without complications.” There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 10/19/23 at 3:40 pm. P-2: This 76-year-old was admitted to the agency on 7/26/23 with diagnoses which included Sepsis (infection in the blood stream); urinary tract infection; and type 2 diabetes. The medical record was reviewed on 10/19/23. During review of the start of care comprehensive assessment dated 7/26/23, it was noted that the diagnosis of type 2 diabetes was given a “Symptom Control Rating” of “3” meaning symptoms were poorly controlled, the patient needs frequent adjustment in treatment and dose monitoring. During review of the plan of care dated 7/26/23 the following skilled nursing (SN) goals were identified: Patient will demonstrate effective self-care management including understanding of ordered medication regimen, signs and symptoms to report, and recommended follow up with physician; Patient will verbalize understanding of medication regimen including name, action, reason for use, evaluation of effectiveness, side effects, and administration instructions; Patient centered long-term goal medication management and ADI independence [sic]. There were no patient-specific goals relating to the patients poorly controlled type 2 diabetes. Additionally, there was no evidence of how the SN goals listed could be objectively measured to determine progress toward the goals. The above findings were reviewed and acknowledged during interview with the Clinical Manager (Staff A) on 10/19/23 at 5:20 p.m.

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 record review and interview, the agency failed to ensure services and treatments found in the plan of care were provided only as ordered by the physician in 3 of 10 (Patient #’s 1, 2, and 7) records reviewed resulting in the potential to negatively affect the health and well-being of these patients. Findings include: P-7: The Start of Care (SOC) was dated 7/10/23. The Plan of Care (POC) identified diagnoses of Emphysema, Pneumonia and Chronic Respiratory Failure. During record review on 10/18/23, the recertification order dated 9/7/23 stated, “SN (Skilled Nurse) 9/17/2023 to 10/14/2023: 2 visits every week for 4 weeks. The SN completed a visit on 9/22/23 and 10/12/23. The SN failed to provide the services and frequency as ordered on the plan of care, completing 2 of 8 ordered visits. No physician order or notification was documented. The skilled nurse failed to provide the services and frequency as ordered by the physician. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 10/19/23 at 3:00 pm. P-1: This 87-year-old was admitted to the agency on 9/26/23 with diagnoses which included open wound to lower legs; venous insufficiency (leg veins which do not allow normal blood flow back to the heart); and heart failure. The medical record was reviewed on 10/18/23. The certification period was noted to be 9/26/23 to 11/24/23. During review of the plan of care (POC) dated 9/26/23, the skilled nursing (SN) orders were noted to include that the SN would monitor for signs and symptoms of exacerbation of congestive heart failure, and that the SN would perform a skilled assessment with focus on weight (among other symptoms). At the time of the medical record review, the SN had made 9 home visits including the start of care (SOC) assessment. The SOC visit was the only visit which documented the patient’s weight. None of the other 8 SN visits in 4 weeks of care recorded a weight, documented that the patient was monitoring their weight, or that the SN was assessing the weight during the visit. P-2: This 76-year-old was admitted to the agency on 7/26/23 with diagnoses which included Sepsis (infection in the blood stream); urinary tract infection; and type 2 diabetes. The medical record was reviewed on 10/19/23. The certification period was noted to be 7/26/23 to 9/19/23. During review of the POC dated 7/26/23, the SN orders were noted to include that a finger stick blood sugar would be checked 1 time daily by either the patient or the SN with parameters which should be reported to the physician, and the SN focus included diabetes education. The SN made 5 visits between 7/26/23 and 8/21/23 and discharged without ever recording a finger stick blood sugar value either taken by the SN or the patient during the 5 weeks of care. The above findings were reviewed and acknowledged during interview with the Clinical Manager (Staff A) on 10/19/23 at 5:20 p.m.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure coordination of care for the identification of patient needs and communication to the appropriate professional, and to the physician in 2 of 10 (Patient #2, 8) records reviewed resulting in potential for decline in the patient's health status and negative outcomes. Findings include: P-2: This 76-year-old was admitted to the agency on 7/26/23 with diagnoses which included Sepsis (infection in the blood stream); urinary tract infection; and type 2 diabetes. The medical record was reviewed on 10/19/23. The plan of care (POC) certification period was 7/26/23 to 9/19/23 and included orders for skilled nursing (SN), medical social work (MSW) and therapy disciplines. The POC also contained orders for daily blood sugar readings to be taken either by the patient or the SN and had an SN focus which included diabetes education. In the start of care (SOC) comprehensive assessment visit dated 7/26/23, it was noted that the diagnosis of type 2 diabetes was given a “Symptom Control Rating” of “3” meaning symptoms were poorly controlled, the patient needs frequent adjustment in treatment and dose monitoring. It was also noted in the above dated SOC that the SN documented the current glucometer in the home was not working properly per the patient, the patient was not currently using it, and the patient was getting a new glucometer on 8/1/23. The next SN visit was 8/3/23 (8 days later), and the SN documented the patient was buying a glucometer “today”. On the next SN visit on 8/10/23 (15 days since SOC), the SN documented that the patient still had not gotten the glucometer and was not sure a new one could be afforded. The nurse made 2 additional visits, one on 8/13/23 and an SN discharge visit on 8/21/23 both with SN documentation stating the patient still had not obtained a glucometer. The SN did not ever record or obtain any blood sugar values and discharged the patient after 27 days of care. There was no evidence that the SN collaborated with the physician or the MSW regarding issues obtaining the ordered daily blood sugar monitoring, or financial need for getting a new properly functioning glucometer. The MSW made 4 visits in the 8-week certification period. There was no evidence the MSW collaborated care with the SN or, became aware of the patient’s difficulty in affording a glucometer. Blood sugar reporting and/or monitoring was not noted to be a goal for any other discipline making visits during the certification period and no documentation regarding such was found. The above findings were reviewed and acknowledged during interview with the Clinical Manager (Staff A) on 10/19/23 at 5:20 p.m. P-8: This 53-year-old patient was admitted to the home health agency on 6/19/23 with the diagnoses of unspecified encephalopathy (disease of the brain), compartment syndrome in the right lower leg (a condition that causes extreme pain due to swelling of tissues) and a wound of the right lower leg due to a procedure performed for the compartment syndrome. During record review on 10/18/23, it was noted the patient called the triage/on call number on 7/22/23. The intake note stated, "Pt. called reporting her toes appear black and she had numbness and tingling. States this is new today. ER (emergency room) advised. Verbalizes understanding." Upon further review of the record, it was noted the patient had a home health visit with skilled nursing on 7/24/23. There was no mention of the nurse being aware of the triage call, therefore there was no follow-up on the situation that prompted the patient's call. It was unclear if the patient went to the emergency room as suggested. There was also no evidence the call information was communicated between the staff to ensure coordination of care and services. Upon further record review on 10/18/23, it was noted social work services were ordered 1 time per week for 1 week the week of 6/26/23. The social worker attempted to contact the patient multiple times and was unable, so the order was changed to 1 time per week for 1 week the week of 7/2/23. The social worker was still unable to make contact with the patient, so orders were made to discontinue services at that time. On 8/3/23, the social worker made a well check visit to the patient and reported she would return for an evaluation after the patient had surgery due to the many needs identified during the wellness check. The patient's surgery was initially scheduled for 8/9/23 but had to be rescheduled until the patient stopped smoking for 2 weeks. The social work evaluation was not performed and there was no documentation regarding the plan for rescheduling. The plan of care dated 8/16/23 to determine the need for further services identified "poor social support" and "lack of adequate transportation" as reasons for needing an evaluation from social work. As of 10/20/23, no social work evaluation had been completed. Findings were reviewed with and acknowledged by the Clinical Manager (Staff A) during an interview on 10/19/23 at 3:55 p.m.

Services provided by HH aide CFR(s): 484.80(g)(2) A home health aide provides services that are: (i) Ordered by the physician or allowed practitioner; (ii) Included in the plan of care; (iii) Permitted to be performed under state law; and (iv) Consistent with the home health aide training. This ELEMENT is not met as evidenced by: Based and record review and interview, the agency failed to ensure the aide provided care as instructed for 1 (Patient #8) of 3 records reviewed in which aide services were provided, resulting in the potential for poor patient outcomes. Findings include: P-8: This 53-year-old patient was admitted to the home health agency on 6/19/23 with the diagnoses of unspecified encephalopathy (disease of the brain), compartment syndrome in the right lower leg (a condition that causes extreme pain due to swelling of tissues) and a wound of the right lower leg due to a procedure performed for the compartment syndrome. During record review on 10/18/23, it was determined aide services were ordered to start on 8/3/23 for 1 time per week and 2 times a week for 2 weeks after that. The aide care plan for this patient indicated the aide is to take vitals at every visit - including pulse, temperature, respirations and blood pressure. The aide only saw the patient for one visit (dated 8/3/23), but there were no vitals recorded on this day. The Clinical Manager (Staff A) was interviewed on 10/19/23 at 3:55 p.m. regarding the orders. Staff A stated the aide probably did not update her electronic medical record system prior to seeing the patient that day, so didn't see the orders added that were put in that morning. The aide did not see the patient until 4:00 p.m. that day. Staff A acknowledged this could be a problem in communicating pertinent information regarding patient care.

Administrator appointed by governing body CFR(s): 484.105(b)(1)(i) (i) Be appointed by and report to the governing body; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to provide documented evidence that an agency administrator was appointed by the governing body, resulting in no definitive lines of authority and the potential for lack of oversight in patient care and operations. Findings include: During entrance conference on 10/17/23 at 3:42 p.m., the Clinical Manager (Staff A) was queried to the name of the agency administrator. Staff A stated that she was unsure due to differences in the agency titles but the administrator currently on file with the State (Staff C) was no longer administrator over the home care side of the agency (and instead was now over the hospice side only). On 10/18/23 at 2:10 p.m., Staff A was queried as to whom was appointed by the governing body to become the administrator after Staff C went to the hospice side of the agency. Staff A stated that the Vice President of Operations of Home Health (Staff B) was over the home health side of the agency but had not yet been appointed as administrator by the governing body. Staff A also stated that a CMS Form 855A had not been filed for change of administrator. The organizational chart was requested and reviewed on 10/18/23. It was noted that Staff C was not on the organizational chart for home health. Staff B was on the organizational chart and listed as the Vice President of Operations of Home Health. This finding was reviewed and acknowledged during interview on 10/20/23 at 9 a.m. with Staff A and Staff B.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure clinical notes were accurate for 1 of 10 (Patient #’s 5) records reviewed, resulting in the potential to negatively affect the health and well-being of these patients. Findings include: P-5: The Start of Care (SOC) was dated 9/16/23. The Plan of Care (POC) identified diagnoses of Pneumonia, Hypertensive Heart and Chronic Kidney Disease, Diabetes Type 2 and Congestive Heart Failure. During record review on 10/18/23, it was noted that the POC ordered Skilled Nursing (SN) at a frequency of 1w4 (1 time a week for 4 weeks). The comprehensive assessment dated 9/16/23 and the following SN visit on 9/20/23 contained no blood sugar readings. Additionally, the comprehensive assessment stated a weight of 105 pounds. The following 3 SN visits contained no weight recordings: 9/20/23, 9/27/23 and 10/4/23. The agency failed to ensure that the medical record was complete and accurate. These findings were reviewed with and acknowledged by the Staff A (Clinical Manager) during an interview on 10/19/23 at 3:00 pm.

Interventions and patient response CFR(s): 484.110(a)(2) All interventions, including medication administration, treatments, and services, and responses to those interventions; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the clinical record contained all interventions and treatments for the patient in 2 (Patient #9, 10) of 10 records reviewed, resulting in a lack of information for all agency staff caring for the patient as well as an inaccurate clinical record. Findings include: P-9: This 95-year-old patient was admitted to the home health agency on 1/9/23 with the diagnosis of a non-traumatic chronic subdural hemorrhage (bleeding around the brain). During record review on 10/18/23, it was noted the physical therapy evaluation dated 1/9/23 identified a goal stating, "Patient will with min (minimal) assist with initial HEP (home exercise program) of seated leg strengthening exercises in order to progress strength and functional mobility." Upon further review, it was determined there was no evidence of a home exercise program in the record or documentation to describe which exercises had been given to the patient to perform at home. P-10: This 84-year-old patient was admitted to the home health agency on 9/7/23 with the diagnoses of a pressure ulcer of the sacral (tailbone) region, acute kidney failure, and type II diabetes. During record review on 10/18/23, it was noted the physical therapy evaluation dated 10/2/23 identified a goal stating, "Patient and/or caregiver will independently with initial HEP (home exercise program) of strengthening, balance training and conditioning in order to progress strength and functional mobility. To be met by 10/13/23." During a home visit with the physical therapist on 10/18/23 10:40 a.m., the patient was asked if she had received a handout with exercises to perform at home. The patient stated she thought she had but was unsure of where it was or what was on it. An updated/advanced handout was provided to the patient during the visit. The patient was unable to describe any exercises she was supposed to be performing on her own. Upon further review of record after the home visit, there was no evidence of a home exercise program in the record or documentation to describe which exercises had been given to the patient to perform at home. During an interview with the Clinical Manager (Staff A) on 10/19/23 at 3:55 p.m., Staff A stated she knows the home exercise program (HEP) is put into the record, but she wasn't sure where to find it at the time. She stated she would ask one of the therapists, however she did acknowledge that she could not find any evidence of an HEP given to the patient. No evidence of HEP documentation was provided by the completion of the survey on 10/20/23.