Every finding on record at Total Care Nursing Services

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 400 Corporate Pointe Walk, 3rd floor, Culver City CA 90230 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44802, Health Facilities Evaluator Nurse Unduplicated Admissions - 6 Active Patients - 6 Sample Size - 8 Home Visits- 3 Old Address: 3450 Wilshire Blvd, Suite 1003 , Los Angeles CA 90010 New Address: 400 Corporate Pointe Walk, 3rd floor, Culver City CA 90230

Develop EP Plan, Review and Update Annually CFR(s): 484.102(a) §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This STANDARD is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to ensure office and field staff had training and annual update regarding the emergency preparedness program (EP, the steps taken to make sure patients and staffs are safe before, during and after an emergency or natural disaster) as indicated in their policy and procedure. This deficient practice had the potential that staffs will not be able to provide the skills and knowledge on how to respond effectively during an emergency situations. Findings: During a concurrent interview with the Director of Patient Care Services (DPCS) and Administrator (Admin) on 9/4/22 at 2:05 p.m., the DPCS stated the office and field staff had an in-service and drill via zoom. DPCS was not able to provide documented evidence to indicate all staffs had attended the in-service training on site, via telephone or video in-service. During a review of the HHAS's document titled "All hazard Emergency preparedness Policy" indicated the director who serves as the Incident Commander, has the authority to activate and deactivate this EP plan based on the information known to her/him at the time which indicates such need. if the Director is not available, the Assistant director, and then the chielf clinical officer will have the authority to activate the response plan. Goal: Allow smooth transistion of patient services and ensure quality of care for all patients served by this agency. Objectives: to be readily available to assist emergency responder personnel in first aid care for those in the community. To provide those patients with the care and assistance that they need in the event of an emergency. Drills: agency staff members will participate in an annual desktop drill to determine the effectiveness and efficiency of the current policy and any forms developed for use in a disaster. Total care Nursing services Emergency operations Plan(EOP) will undergo an annual review process to ensure any plan deficiencies are identified and addressed. A corrective action process will be instituted and maintained in the plan to ensure lessons learned and action items identified from exercises and real events are properly addressed and documented.

The following reflects the findings of the California Department of Public Health during a Recertification Survey at this location: 400 Corporate Pointe Walk, 3rd floor, Culver City CA 90230 Representing the California Department of Public Health: Surveyor # 44916, Health Facilities Evaluator Nurse Surveyor # 44802, Health Facilities Evaluator Nurse Unduplicated Admissions - 6 Active Patients - 6 Sample Size - 8 Home Visits- 3 Old Address: 3450 Wilshire Blvd, Suite 1003 , Los Angeles CA 90010 New Address: 400 Corporate Pointe Walk, 3rd floor, Culver City CA 90230 One Condition of Participation was not met: 484.60 Condition of Participation: Care planning, coordination of services and quality of care.

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 observation, interview and record review, the home health agency (HHA) failed to ensure the Condition of Participation for Care Planning, Coordination, and Quality of Care was met as follows: 1. The HHA failed to ensure to develop and implement a plan of care (POC) for four of seven sampled patients (Patient 1, Patient 2, Patient 4 and Patient 5). For Patient 1, the HHA did not develop and implement a POC for Patient 1's abscess (a swollen area within body tissue, containing an accumulation of pus) to abdomen (commonly called belly). For Patient 2, 4, and 5, the HHA failed to ensure, an individualized plan care for the use of anticoogulants (medication that help to stop the blood from thickening or clotting). For Patient 5, the HHA failed to develop and implement a plan of care for wounds to buttocks, sacrum, coccyx and right great toe. This failure could result in delay and lack of wound care treatment and adverse effect, and lack of services necessary to meet the patients care goals. Refer to G574. 2. The HHA failed to ensure, the patients' physician was notified and obtain wound care treatment orders for Patient 1's abscess to abdomen and Patient 5's wounds. Refer to G580 The cumulative effect of these systemic practices resulted in the agency's failure todeliver statutorily mandated compliance with Federal regulations for Care planning, Coordination, and Quality of care to ensure provision of highest quality of care to the patient. Refer to G574 and G580.

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 observation, interview, and record review the home health agency (HHA) failed to develop and implement plan of care (POC) four sampled patients (Patient 1, 2, 4, and 5). The HHA failed to ensure to develop and implement POC for Patient 1's abscess (a swollen area within body tissue, containing an accumulation of pus) to abdominal wall, wound care. The HHA failed to ensure Patient 2, 4, and 5, had individualized plan of care for the use of anticoagulants (medications that help to,stop the blood from theckening or clotting). This failure had the potential to delay necessary care and treatment and cause serious complications that could affect the patients health status and well being. b. A review of the Patient 2’s Patient Profile indicated a start of care (SOC) date on 5/12/2022 with diagnoses including transient cerebral ischemic attack (condition where blood flow to a part of the brain stops for a brief time and a person will have stroke-like symptoms for up to 24 hours), right shoulder pain and hypertension (high blood pressure). A review of Patient 2's plan of care (POC) from the certification period from 7/11/2022 to 9/8/2022 included an order for the skilled nurse to visit once a week for nine weeks. The POC indicated the skilled nurse (SN) to perform comprehensive skilled nursing assessment, observation and evaluation of all body systems and assess vital signs, medication and diet compliance, and safety on every visit. A review of Patient 2’s Medication Profile indicated for Eliquis (anticoagulant), 2.5 milligram (mg) oral tablet, one tablet twice a day. Further review of Patient 5’s clinical record indicated no care plan was developed identifying the use of anticoagulant medications. c. A review of the Patient 4’s Patient Profile indicated a start of care (SOC) date on 6/16/2022 with diagnoses including of cerebral infarction (stroke), hypertension (high blood pressure), and diabetes (diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of Patient 4's plan of care (POC) from the certification period from 6/17/2022 to 8/15/2022 included an order for the skilled nurse to visit twice a week for two weeks and then once a week for seven weeks. The POC indicated the skilled nurse (SN) to perform comprehensive skilled nursing assessment, observation and evaluation of all body systems and assess vital signs, medication and diet compliance, and safety on every visit. A review of Patient 4’s Medication Profile indicated for Eliquis (anticoagulant), 2.5 milligram (mg) oral tablet, one tablet twice daily. Further review of Patient 4’s clinical record indicated no care plan was developed identifying the use of anticoagulant medications. d. A review of the Patient 5’s Patient Profile indicated a start of care (SOC) date on 3/2/2022 with diagnoses including of ischemic cardiomyopathy (a condition where the heart has decreased ability to pump blood properly due to heart muscle damage resulting in inadequate blood supply) and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 5's plan of care (POC) from the certification period from 6/30/2022 to 8/28/2022 included an order for the skilled nurse to visit once a week for nine weeks. The POC indicated the skilled nurse (SN) to perform comprehensive skilled nursing assessment, observation and evaluation of all body systems and assess vital signs, medication and diet compliance, and safety on every visit. A review of Patient 5’s Medication Profile indicated for Aspirin, 81mg, one tablet by mouth once daily and Clopidogrel (anticoagulant), 75 mg, one tablet by mouth once daily. Further review of Patient 5’s clinical record indicated no care plan was developed identifying the use of anticoagulant medications or for the treatment for wounds. During an interview on 9/5/2022 at 2:30 pm, the Director of Patient Care Services (DPCS) stated patients on an anticoagulant should have a care plan to check for signs and symptoms of bleeding. During an interview on 9/5/2022 at 2:40 pm, the DPCS stated prior to performing wound treatment, there needs to be a physician order. The DPCS stated the POC should have included that the SN assess the wound every visit for redness, odor, drainage, and size and carry out the wound care treatment as ordered. The further stated the SN should document the wound assessment and the wound care treatment in the SN notes. A review of the HHA’s policy, Plan of Care (undated), indicated the Plan of Care is based on a comprehensive assessment and information provided by the client/family and health team members. The policy indicated to develop a plan of care individualized to meet specific identified needs. A review of the HHA’s policy, Wound Care Policy (undated) indicated the clinician, in conjunction with the patient and caregiver, will develop an appropriate plan of care based on the patient’s needs and the assessment findings. Each patient will be evaluated and treated using an individualized care plan based on the patient’s unique medical condition. 1. A review of the Patient 1’s Patient Profile indicated a start of care (SOC) date on 8/20/2022 with diagnoses including cutaneous abscess of the abdominal wall( is a pocket of pus or infected fluid that is surrounded by inflamed tissue inside the belly located in the abdomen). A review of Patient 1's plan of care (POC) from the certification period from 8/20/2022 to 10/25/2022 included an order for skilled nursing to perform resumption of care to be initiated on 9/3/2022. A home visit was conducted on 9/3/2022 at 8:19 a.m., with the Director of Patient Care Services (DPCS) at Patient 1's home. Patient 1 is alert and verbally responsive, able to make needs known, walks around the home with the use of a cane and walker. Patient 1's son is present and DPCS proceeded with her visit. During an observation of the home visit, DPCS performed hand hygiene and asked where the wound care supplies kept. Observed a white envelope on top of the table. DPCS did not inquire what the envelope contained nor did she ask any discharge papers from the hospital. On concurrent interview with the DPCS, DPCS stated Patient 1 was seen by the agency for some time now until patient was transferred to the hospital for her abscess on the abdominal wall. DPCS instructed the patient to lie down on her bed to perform wound care. DPCS did not verify wound care orders from doctor. A review of Patient 1's discharge papers dated 8/31/2022 from the acute hospital indicated "Comments/Recommendations" "Fistulous opening- change pouching system Q5-7 days of PRN( as needed) if leaking. Applied layer of medical adhesive over top layer of anti-fungal powder. Performed crusting technique. Cut slits to accommodate skin folds, which is the primary challenge for adherence of technique. Reinforced with barrier strips. Drs Bland and Hunter at bedside.Discussed with them plan for continued pouching (pt. pending D/C friday) Discussed with dr. Ivy earlier in AM. patient to call her goddaughter for additional training tomorrow morning. Discussed with Registered nurse (RN) to have me paged tomorrow when family arrived for training. Will order and determine pouching needs tomorrow." During an interview with the DPCS on 9/4/2022 at 2:05 p.m., DPCS stated should have went over the discharge papers first and verify wound care orders from primary physician. DPCS also stated to perform proper wound assessment then give report to the physician and then verify wound care orders should be done first before performing any wound care to any patient.

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 interview and record review, the HHA, the skilled nurse (SN) failed to notify and obtain wound care treatment orders for two of seven patients (Patient 1 and Patient 5). This deficient practice placed the patient's wound sites at risk for infection and delay in the healing process. A review of the Patient 5’s Patient Profile indicated a start of care (SOC) date on 3/2/2022 with diagnoses including of ischemic cardiomyopathy (a condition where the heart has decreased ability to pump blood properly, due to heart muscle damage due to an inadequate blood supply) and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing).). A review of Patient 5's plan of care (POC) from the certification period from 6/30/2022 to 8/28/2022 included an order for the skilled nurse to visit once a week for nine weeks. The POC indicated the skilled nurse (SN) to perform comprehensive skilled nursing assessment, observation and evaluation of all body systems and assess vital signs, medication and diet compliance, and safety on every visit. The POC did not include orders for wound treatment. A review of Patient 5’s Recertification assessment, dated 6/27/2022, indicated no Stage I [(superficial reddening of the skin (or red, blue or purple hues in darkly pigmented skin) that when pressed does not turn white)] or Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough) pressure ulcers. A review of Patient 5’s Wound Sheet Assessment and Treatment, dated 7/6/2022 indicated Patient 5 with wound to buttocks, sacrum, and coccyx. The Wound Sheet indicated several small bilateral decubitus and wound status as Stage I . The Wound Sheet indicated treatment order for the buttocks, sacrum, coccyx to cover decubs with Mepilex and ointment; keep area dry and clean. The Wound Sheet indicated a wound on the right great toe described as a raised whitish sore that appeared open and staged as “Stage I vs Stage II .” The Wound Sheet indicated treatment order for the right great toes to cover open sore with Mepilex and ointment after cleaning. There was no documented evidence of a notification of change to the Physician about Patient 5’s wounds. There was no documented evidence of a physician order to treat Patient 5’s wounds. During an interview on 9/5/2022 at 2:40 pm, the DPCS stated prior to performing wound treatment, there needs to be a physician order. The DPCS stated the POC should have included that the SN assess the wound every visit for redness, odor, drainage, and size and carry out the wound care treatment as ordered. The further stated the SN should document the wound assessment and the wound care treatment in the SN notes. During an interview on 9/5/2022 at 2:45 pm, the DPCS stated the wound care order for Patient 5's wounds could not be located. 1. A review of the Patient 1’s Patient Profile indicated a start of care (SOC) date on 8/20/2022 with diagnoses including cutaneous abscess of the abdominal wall( is a pocket of pus or infected fluid that is surrounded by inflamed tissue inside the belly located in the abdomen). A review of Patient 1's plan of care (POC) from the certification period from 8/20/2022 to 10/25/2022 included an order for skilled nursing to perform resumption of care to be initiated on 9/3/2022. A home visit was conducted on 9/3/2022 at 8:19 a.m., with the Director of Patient Care Services (DPCS) at Patient 1's home. Patient 1 is alert and verbally responsive, able to make needs known, walks around the home with the use of a cane and walker. Patient 1's son is present and DPCS proceeded with her visit. During an observation of the home visit, DPCS performed hand hygiene and asked where the wound care supplies kept. Observed a white envelope on top of the table. DPCS did not inquire what the envelope contained nor did she ask any discharge papers from the hospital. On concurrent interview with the DPCS, DPCS stated Patient 1 was seen by the agency for some time now until patient was transferred to the hospital for her abscess on the abdominal wall. DPCS instructed the patient to lie down on her bed to perform wound care. DPCS did not verify wound care orders from doctor. A review of Patient 1's discharge papers dated 8/31/2022 from the acute hospital indicated "Comments/Recommendations" "Fistulous opening- change pouching system Q5-7 days of PRN( as needed) if leaking. Applied layer of medical adhesive over top layer of anti-fungal powder. Performed crusting technique. Cut slits to accommodate skin folds, which is the primary challenge for adherence of technique. Reinforced with barrier strips. Drs Bland and Hunter at bedside.Discussed with them plan for continued pouching (pt. pending D/C friday) Discussed with dr. Ivy earlier in AM. patient to call her goddaughter for additional training tomorrow morning. Discussed with Registered nurse (RN) to have me paged tomorrow when family arrived for training. Will order and determine pouching needs tomorrow." During an interview with the DPCS on 9/4/2022 at 2:05 p.m., DPCS stated should have went over the discharge papers first and verify wound care orders from primary physician. DPCS also stated to perform proper wound assessment then give report to the physician and then verify wound care orders should be done first before performing any wound care to any patient.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on observation, interview, and record review, the home health agency (HHA) failed to maintain and implement their agency-wide program for the surveillance, identification, prevention, control, and investigation of COVID-19 ( an acute serious respiratory illness) This failure had the potential to expose patients, staff and visitors to COVID-19 infection and cause potentially cause serious harm, hospitalization and even death. During recertification survey entrance on 9/2/2022, at 3:40 p.m., there was no COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) screening procedures performed for visitors, office and field staff upon entrance to the home health agency (HHA). During an observation on 9/4/2022 at 10:15 a.m., there was no COVID-19 screening procedures performed at the entrance for visitors, office, and field staff upon entrance to the HHA. During an interview on 9/4/2022 at 2:05 p.m., the Director of Patient Care Services (DPCS) stated that infection control in-service were done via zoom meeting. When asked to provide documentation for in-services, the DPCS could not provide written evidence of infection control in-service attendance. DPCS further stated that there will be "possible exposure to staff and patients if infection control procedures are not followed." A review of the HHA's document B-402 titled, "Infection Control Surveillance", indicated that agency will establish a continuous data monitoring and collecting system to detect infections or identify changes in infection trends. The three types of surveillance that may be used are: Total surveillance- all infections identified, populations and employees Targeted Surveillance- specific infections, populations or procedures Outbreak Surveillance- specific infections or infection clusters within multiple individuals at the same time. The Agency will implement a process of identifying all infections in the client and /or employee population and evaluate effectiveness of current control measures or identify an action plan to improve incidence of infection. A review of the HHA's document B-403 titled "Infection prevention and Control", indicated agency will observe the recommended precautions for home care as identified by the Centers for Disease control and prevention (CDC). The precautions cover those clients with documented or suspected infection with highly transmissible or epidemiologically important pathogens that require additional precautions to prevent transmissions. The agency will have an infection prevention and control component to the infection program. This program will evaluate those populations to be at risk and implement processes as needed. Purpose is to ensure employee and client safety. To reduce the risk of transmission of microbes from both recognized and unrecognized sources of infection. Infection control policies and procedures will be reviewed annually or as indicated.

Patient and caregiver education CFR(s): 484.75(b)(5) Patient and caregiver education; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to provide its patients and caregivers with sufficient information regarding the services provided for 1 of 7 sampled patients, (Patient 1). This failure had the potential to result in the HHA's inability to provide the quality care and services for all the patients under their care. A review of the Patient 1’s Patient Profile indicated a start of care (SOC) date on 8/20/2022 with diagnoses that included cutaneous abscess wall (a pocket of pus or infected fluid) of the abdominal. A review of Patient 1's plan of care (POC) for the certification period 8/20/2022 to 10/25/2022 included an order for skilled nursing to perform resumption of care to be initiated on 9/3/2022. A home visit was conducted on 9/3/2022 at 8:19 a.m., with the Director of Patient Care Services (DPCS) at Patient 1's home. Patient 1 was alert and verbally responsive, able to make needs known, walk around the home with the use of a cane and walker. Patient 1's son was present and DPCS proceeded with her visit. During an interview on 9/3/22 at 9:00 a.m., with Patient 1 and the caregiver, Patient 1 expressed feelings of sadness when Patient 1 stated " I do not know what I can eat because of this." Patient 1 also stated he wanted to see a Dietitian to know what he can eat. Patient 1's caregiver also stated, " I did not know that we can ask those services to the home health agency." Patient 1's caregiver also expressed interest in knowing what other services Patient 1 can have from the agency." During an interview with the DPCS on 9/4/22 at 2;50 p.m., DPCS stated she will provide in-service to all staff on the importance of patient and caregiver education about other services appropriate for patient care. A review of the undated HHA's policy and procedure titled, " Patient Education", indicated to provide patients/families/caregivers with sufficient information to make informed decisions and to take responsibility for self-management/management activities relative to patient needs, appropriate to the care, treatment and/or services provided. To improve patient outcomes by educating the patient and family/caregiver with the patient's permission, as appropriate, by promoting recovery, lifestyle modifications and healthy behavior utilizing a multidisciplinary approach. All patients admitted to Total care nursing services for care, treatment and/or services, patient and/or family members/caregivers are provided with appropriate education and training specific to needs identified during the initial and ongoing assessments, learning preferences and readiness to learn as appropriate to the care, treatment and/or services provided by Total care Nursing Services.

Required items in clinical record CFR(s): 484.110(a)(1) The patient's current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This ELEMENT is not met as evidenced by: Based on interview and record review, the home health agency (HHA) failed to complete Skilled Nursing (SN) notes in a timely manner for one of seven sample patients, (Patient 5). This deficient practice placed the patient at a potential risk for not receiving the skilled nursing care services as needed. A review of the Patient 5’s Patient Profile indicated a start of care (SOC) date on 3/2/2022 with diagnoses that included ischemic cardiomyopathy (a condition where the heart has decreased ability to pump blood properly due to heart muscle damage resulting in inadequate blood supply) and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 5's plan of care (POC) for the certification period 6/30/2022 to 8/28/2022 included an order for the skilled nurse to visit once a week for nine weeks. The POC indicated the skilled nurse (SN) to perform comprehensive skilled nursing assessment, observation and evaluation of all body systems and assess vital signs, medication and diet compliance, and safety on every visit. The POC did not have orders for wound treatment. A review of SN notes dated 7/6/2022 through 8/5/2022 indicated wound type was left blank. There was no documented evidence of SN comprehensive assessments for the weeks of 8/8/2022 through 8/28/2022. There was no documented evidence of Wound Sheet Assessment and Treatment performed from 7/13/2022 through 8/28/2022. During an interview on 9/5/2022 at 2:45 pm, the Director of Patient Care Services (DPCS) stated Patient 5’s SN notes should have been completed after the SN visited the patient. The DPCS stated that the skin assessment for the pressure ulcers also should have been documented on the SN notes. A review of the HHA’s undated policy and procedure titled, “Clinical Records/Medical Record Retention”, indicated a required documentation for each service or care provided must be completed on a day the services is rendered and filed in the clinical record withing seven (7) days.