Every finding on record at My Home Hospice Company

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current p prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, and other alternative treatments that could affect drug therapy. The medication review process includes the identification of the following: the effectiveness of drug therapy, drug side effects, actual or potential drug interactions, duplicate drug therapy, drug therapy associated with laboratory monitoring. The assessment includes evidence that common side effects of medication in the hospice populations are anticipated, and as appropriate, preventive measurements are implemented to manage the side effects. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added, or changes are made to existing medication. This standard was not met as evidenced by clinical record review, document review, interview, and observation. In 1 of 5 (20%) clinical records reviewed and home visit observations revealed that the agency did not ensure that the medication profile initial or subsequent comprehensive assessments included a drug profile that contained the patient's current prescription and over the counter (OTC) drugs. Agency Policy: #PC.17 "Medication List and Monitoring" stated in part, "Agency will maintain a current, accurate list of all prescription and over the counter (OTC) medications taken by the patient." Clinical Record 3/Home Visit 1: The patient elected hospice care on 07/14/2023. The initial RN comprehensive assessment was dated 07/14/22. During the home visit observation with the RN (Personnel Record 3) on 12/26/23 revealed that the patient had Zofran 4mg po q 6hrs prn ordered on admission. A review of the patient's drug profile revealed the medication was not a part of the medication profile and reconciliation.

It is required that if the care of a hospice patient is transferred to a Medicare/Medicaid certified facility, the hospice forwards to the receiving facility a copy of the hospice discharge summary described in HCDT 40.I; and the patient’s record, if requested. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 2 (50%) discharged records reviewed where the patient revoked and transferred to a Medicare/Medicaid/MediCal facility for aggressive treatment, the agency did not ensure that the discharge summary was forwarded to the receiving facility for continuity and coordination of patient care. Agency Policy: # PE.5 Stated in part " Prior to a transfer, the agency will provide the receiving agency with a discharge summary, medication profile, copy of the patient's clinical record, if requested." Clinical Record 1: The patient’s election of hospice benefit was dated 10/09/2023 with a diagnosis of cerebral vascular accident (CVA). The patient revoked the hospice benefit on 11/15/2023 to seek aggressive treatment at a local hospital. A discharge summary was completed but there was no documented evidence that the discharge summary was provided to the receiving hospital for coordination of care. During the interview with the Registered Nurse (RN) on 12/27/2023 confirmed the discharge summary and/or patient clinical record was not sent to the receiving hospital to ensure coordination of care.

It is required that the designates an Interdisciplinary Group or groups who, in consultation with the patient's attending physician, prepare a written plan of care (POC) for each patient. The plan of care specifies the hospice care and services necessary to meet the specific needs of the patient and family identified in the comprehensive assessment, relative to the terminal illness and associated conditions. THIS IS A CMS CONDITION LEVEL DEFICIENCY. This CONDITION was not met as evidenced by clinical record review and interview, the hospice as follows: Failure to include on the POC patient and family goals and interventions based on problems identified in the comprehensive assessment [418.56(c)/L545]; Failure to follow the visit frequency necessary to meet the patient and family specific needs according to the individualized care plan [418.56(c)(2)/L547]; Failure to ensure the RN member of the ODG provided coordination of care [418.56(a)/L540]; and Failure to ensure that each patient's individualized Plan of Care included measurable outcomes of care [HCPC.21.I/L548/418.56(c)(3)]. The cumulative effect of these deficiencies could negatively impact the organization's ability to provide safe and effective quality patient care services.

It is required that the hospice designates a registered nurse member of the IDG to provide coordination of care; ensure continuous assessment of each patient’s and family’s needs, and ensure the implementation of the interdisciplinary plan of care. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 1 (100%) clinical records reviewed in which patient's received services provided from an outside agency revealed that the agency did not ensure the RN member of the IDG provided coordination of care. Document 1: The hospice policy "Interdisciplinary Team, Coordination of Care and Services" (PC.8) dated 1/15/09 and reviewed and adopted 7/19/2023 stated that, "The IDT ...will supervise the care and services and ... Communication. regarding the patient's plan of care ...includes informal verbal and written communication among all staff members providing care. This will serve as documentation of effective interchange and reporting, as well as coordination of care. Documentation in the clinical record will also reflect coordination with community resources, as well as other care providers. " The policy also stated, "...provide for and ensure the ongoing sharing of information between all disciplines providing care ...whether the care and services are provided directly or under arrangement." In the agency policy "Coordination of Care with Community Resources" (PC.22) dated 1/10/2013 and reviewed and adopted 7/19/2023 read, "The agency will insure coordination of care, with outside resources that are providing care for the hospice patient. The hospice will collaborate, coordinate and advocate for the patient to achieve non-duplication of services and to facilitate the exchange of information, reporting, and coordination of client services. The hospice case manager will insure that this coordination of care is reflected in the clinical record." "The hospice staff will review the hospice plan of care, and the outside entities plan of care, to determine any duplication of service, and to ensure the patient receives the services the patient needs... The hospice staff and the outside entity will collaborate to facilitate a mutual plan of care for the hospice patient." "The hospice staff member will include the outside entity's care in the IDT comprehensive plan of care. The IDT will review these services, through the plan of care, in the IDT meeting. Clinical Record 3: The patient elected the hospice benefit on 7/18/2023. During the Home Visit observation on 10/4/2023, the patient reported that he was receiving regular Physical Therapy (PT). A physician order dated 8/12/2023 received by the hospice documented "Physical Therapy to see patient to evaluate and treat. Therapy includes home exercise programs with safety precautions, ROM with strengthening, gait training, transfer training, balance activities and bed mobility. (Plus 2 PRN visits if necessary to complete therapy treatment plan) Discharge when goals are met or per patient request." There was no documented evidence of a visit frequency for PT. At the time of record review, there was no documentation in the Care Coordination notes, scanned documents or the Interdisciplinary Group Meetings for 8/3/2023, 8//10/2023, 8/17/2023, 8/31/2023, 9/14/2023, 9/28/2023 of any communication between the hospice and the Physical Therapist documenting the frequency of PT visits, PT interventions, or any of the PT goals/progress. There was no documentation of the RN reporting or discussing the patient's progress or expected progress to the Interdisciplinary Team. There was no documented evidence that the hospice was supervising, coordinating, or covering the cost of the PT visits. On the afternoon of the last day of the site visit on 10/5/2023, the Administrator requested and received a copy of the home health agency's Home Health Plan of Care for dates of care 9/6/2023 - 11/4/2023 in which the frequency and details of the PT visits were documented. The visit frequency was 2 times a week X 8 weeks. This home health agency was not contracted with the hospice to provide PT services. Personnel Record 1: In an interview on 10/4/2023 and 10/5/2023, the Administrator (Staff 1) and Director of Nursing (Staff 3) confirmed that there was no documentation of care coordination between the Interdisciplinary Team (IDT) and the outside agency providing Physical Therapy Services. The DON confirmed the patient was receiving physical therapy services from a home health agency, and there was no collaboration between the two agencies. The DON verified that the Home Health Plan of Care for the Home Health certification period 9/6/2023 - 11/4/2023 had not been received until requested on 10/5/2023.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 5 (60%) clinical records reviewed revealed that the patient's written Plan of Care did not include planned interventions based upon information obtained in the Comprehensive or Updated Comprehensive Assessments. Document 1: The agency policy "Care Planning Process" (PC.6) dated 3/1/2015 and reviewed and adopted on 7/19/2023, in the section entitled Content of the IDT Plan of Care, it read, "...will include identified problems or specific services needed by patient and family...a detailed statement of the scope and frequency of services and interventions planned to meet identified patient/family need." The policy, "Review and Revision of Patient Care" (PC.9) dated 8/1/2004 and reviewed and adopted 7/19/2023 included that, "Agency staff will review patient care each visit. Upon identifying that the patient care needs have changed...adjustments to the care planning documents will be made as follows by MD Orders, IDT Plan of Care ... each change will be accompanied by specific interventions. All written changes to the plan of care will be incorporated into the patient's medical record as changes occur." Clinical Record 3: The patient elected the hospice benefit on 7/18/2023. On admission on 7/18/2023, the nurse identified a Skin Integrity Care Plan problem. The identified interventions were as follows all added on 7/18/2023: assess skin integrity and effectiveness of care each visit and instruct patient/family in principles of maintaining skin integrity. The RN Skilled Visit dated 8/10/2023, the nurse noted, "Patient had some bump type of bite/boil in his ear and side of the head. SN (Skilled Nurse) notified MD, MD approved for continued use of TAO (Triple Antibiotic Ointment) 1-3 times daily until resolved." Next, on 8/16/2023, the RN documented in the RN Skilled Nurse Visit, "SN followed up on Amoxicillin 500mg PO TID ordered on 8/13/2023..." At the time of review, there was not an identified infection/antibiotic care plan, and there was no documented evidence of any identified interventions related to the patient's skin infection and antibiotic therapy. During the home visit observation on 10/4/2023, the patient reported that he was receiving regular Physical Therapy (PT). A physician order dated 8/12/2023 documented "Physical Therapy to see the patient to evaluate and treat. Therapy includes home exercise programs with safety precautions, ROM with strengthening, gait training, transfer training, balance activities and bed mobility. (Plus 2 PNR visits if necessary to complete therapy treatment plan) Discharge when goals are met or per patient request." The problem "Physical Mobility" was added to the patient's Care Plan on 9/16/2023 with the following interventions: provide assistive devices (cane, walker), assess caregiver to provide personal care, instruct caregiver in basic personal care techniques, assist the patient with activities of daily living, teach fall prevention, and educate caregiver to notify hospice of falls or injuries. At the time of record review, there were no identified interventions related to the assessed need for PT services. Clinical Record 4: The patient elected the hospice benefit on 7/29/2023. The Plan of Care Order for the dates 7/29/2023 - 10/26/2023 included the order for the Social Worker to visit the patient once a month. The Social Worker's Initial Assessment visit dated 7/31/2023 noted that the patient had an open APS case and included the Case Worker's name and phone number. Also documented was that the patient did not have an MPOA and did not have anyone she wanted to be her MPOA. Additionally, the patient wanted to be a full code and to pursue hospitalization for life-sustaining treatment if needed. And finally, the patient had no funeral arrangements. The patient lived alone in a rural area with a neighbor who came by to check on her, but that would end in August 2023. In the Social Work visit dated 8/29/2023, it was documented, "Patient unable to get up and do for self. Patient was sleeping on floor. Patient has no family and lives alone in the home. The patient has a lack of family support. While there is food in the home patient is unable to get up and make food for herself. The patient does not have a provider...She is unrealistic about her condition. She has no desire to leave her home." The Plan of Care did not contain interventions related to the noted issues documented by the Social Worker for the patient's safety/APS open case, lack of advanced care planning, unrealistic expectations regarding her health condition and ability to remain living in her home, and lack of funeral arrangements. The patient revoked the hospice benefit on 9/30/2023 to seek hospitalization. Clinical Record 5: The patient elected the hospice benefit on 7/12/2023. The RN Skilled Visit dated 8/14/2023, the nurse noted crackles and rales upon lung auscultation and a productive cough. The patient's oxygen saturation reading was 89% on room air. The physician was notified and a Physician Order was documented 8/14/2023 for Levaquin 500 mg daily for ten days and Prednisone 10mg daily for ten days. The next nursing visit to the patient was on 8/21/2023. At that visit, the nurse noted that the patient's oxygen saturation reading was 88%, a productive cough, dyspneic at rest and wheezing in upper lung fields and right middle lung field. It was documented, "Patient is still taking his Levaquin 500mg to be finished o 8/24/2023, Prednisone 10 mg to be finished on 8/28/2023. Patient is still complaining residual symptoms for respiratory infection ..." In the scanned documents was a report of a chest x-ray performed on 8/24/2023 with the radiologist's impression: "Patchy opacity is seen in both lungs, mildly worse on the left side since previous." At the time of review, there was no identified infection problem. The record identified a problem with the respiratory system that included interventions to assess lung sounds, coughing, and respiratory status, instruction in the principles of energy conservation and oxygen storage, morphine use for dyspnea, and oxygen for shortness of breath. The Plan of Care did not include interventions regarding the identification of a respiratory infection or the measures being taken to address the infection. Personnel Record 3: During an interview on 10/4/2023 and 10/5/202, the Director of Nursing (DON) (Personnel record 3) confirmed the above-referenced patients' individualized Plans of Care were not updated with interventions to address the new information/assessment data.

It is required that each patient’s individualized written plan of care and includes all services necessary for the palliation and management of the terminal illness, including a detailed statement of the scope and frequency of services necessary to meet specific patient and family needs. This standard was not met as evidenced by clinical record review, document review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that the patient's written plan of care included the scope and frequency for the Physical Therapy visits. Document 1: The agency policy "Care Planning Process" (PC.6) dated 3/1/2015 and reviewed and adopted 7/19/2023 read that the content of the IDT Plan of Care will include, "A detailed statement of the scope and frequency of services and interventions planned to meet identified patient/family need and designation of the discipline(s) responsible for providing specific services." Clinical Record 3: The patient elected the hospice benefit on 7/18/2023. During the Home Visit observation on 10/4/2023, the patient stated that the Physical Therapist (PT) had been to his home approximately six times. A physician order dated 8/12/2023 documented "Physical Therapy to see the patient to evaluate and treat. Therapy includes home exercise programs with safety precautions, ROM with strengthening, gait training, transfer training, balance activities and bed mobility. (Plus 2 PNR visits if necessary to complete therapy treatment plan) Discharge when goals are met or per patient request." The record did not contain a visit frequency for the physical therapy visits. Personnel Record 1: During an interview on 10/4/2023 and 10/5/2023, the Administrator (Personnel record 1) and the Director of Nursing (Personnel record 3) confirmed that the patient's physical therapy frequency of visits were not included in the plan of care.

It is required that each patient’s individualized written plan of care includes all services necessary for the palliation and management of the terminal illness, including measurable outcomes anticipated from implementing and coordinating the plan of care. This standard was not met as evidenced by clinical record review, document review and interview. In 3 of 5 (60%) clinical records reviewed revealed that the agency did not ensure that each patient's individualized Plan of Care included measurable outcomes of care. Document 1: The agency policy "Care Planning Process" (PC.6) dated 3/1/2015 reviewed and adopted 7/19/2023 read that the "Content of the Plan of Care will include measurable goals of care/measurable outcomes anticipated from implementing and coordinating the POC." Additionally, "The revised POC will ... note the patient's progress toward outcomes and goals specified in the POC." Clinical Record 3: The patient elected the hospice benefit on 7/18/2023. A physician order dated 8/12/2023 documented "Physical Therapy to see patient to evaluate and treat. Therapy includes home exercise programs with safety precautions, ROM with strengthening, gait training, transfer training, balance activities and bed mobility. (Plus 2 PRN visits if necessary to complete therapy treatment plan) Discharge when goals are met or per patient request." During the Home Visit observation on 10/4/2023, the patient reported that he was receiving regular Physical Therapy. The RN Skilled Nurse Visits dated 9/15/2023 and 9/20/2023 noted that the patient appeared tired during the visit due to his exertion during the Physical Therapist (PT) which had occurred prior to her visit. At the time of review, the problem "Physical Mobility" was added to the patient's Care Plan on 9/16/2023 but without any identified goals for the Physical Therapy visits included. The RN Skilled Visit dated 8/10/2023, documented an assessment of several sores and bumps to the patient's face, head, and ear that the son was using Triple Antibiotic Ointment to treat. On 8/16/2023, the nurse documented in her visit that an order was received from the hospice Medical Director for Amoxicillin 500 mg to be taken by mouth three times daily. On admission on 7/18/2023, the nurse identified a Skin Integrity Care Plan problem. However, at the time of review, the Plan of Care was not updated to include any goals to reflect the updated infection assessment and antibiotic therapy. Clinical Record 4: The patient elected the hospice benefit on 7/29/2023. The Plan of Care dated 7/29/2023 - 10/26/2023 included the order for the Social Worker to visit the patient once a month. During the Initial Social Worker's Assessment visit dated 7/31/2023, it was documented that the patient had an open APS case, had no Medical Power of Attorney (MPOA), was a full code and planned to seek hospitalization for life-sustaining treatment, if needed. and had no funeral arrangements in place. Additionally, she noted that the patient lived alone in a rural area with a neighbor that came by to check on her, but that would end in August 2023. Next on 8/29/2023, during the Social Work visit she noted that the patient was unrealistic about her health, had no provider services, was unable to get up and do the necessary things for herself such as prepare a meal, and lived alone without the support of family. At the time of review, there were no identified goals to address these issues documented by the Social Worker for the patient's safety/APS open case, lack of advanced care planning, unrealistic expectations regarding her health condition and ability to remain living in her home, and lack of funeral arrangements. Patient revoked the hospice benefit on 9/30/2023 to seek hospitalization. Clinical Record 5: The patient elected the hospice benefit on 7/12/2023. In the RN Skilled Visit dated 8/14/2023, the nurse noted the patient with crackles and rales upon lung auscultation and a productive cough. The patient's oxygen saturation reading was 89% on room air. The physician was notified and a Physician Order was documented 8/14/2023 for Levaquin 500 mg daily for ten days and Prednisone 10mg daily for ten days. The next nursing visit to the patient was on 8/21/2023. At that visit the nurse noted that the patient's oxygen saturation reading was 88%, a productive cough, dyspneic at rest and wheezing in upper lug fields and right middle lung field. It was documented, "Patient is still taking his Levaquin 500mg to be finished o 8/24/2023, Prednisone 10 mg to be finished on 8/28/2023. Patient is still complaining residual symptoms for respiratory infection ..." In the scanned documents was a report of a chest x-ray performed 8/24/2023 with the radiologist's impression: "Patchy opacity is seen in both lungs, mildly worse on the left side since previous." At the time of review, there were no identified expected outcomes documented in the patient's plan of care with the treatment plan of Levaquin, Prednisone, and the subsequent chest x-ray. The patient revoked the hospice benefit on 8/25/2023 to seek aggressive treatment. It was confirmed during an interview with the Director of Nursing (DON) (Staff 3) on 10/4/2023 and 10/5/2023 that at the time of the clinical record review the above-referenced patients' individualized Plans of Care did not include goals and measurable outcomes for issues identified in the comprehensive and updated comprehensive assessments.

It is required that a hospice ensures that “non-core” services are available and provided directly by the hospice or under arrangement. The following “non-core” services are provided in a manner consistent with current standards of practice: Physical therapy; Occupational therapy; and Speech-language pathology services. THIS IS A CMS CONDITION LEVEL DEFICIENCY This CONDITION This Condition was not met as evidenced by This standard was not met as evidenced by clinical record review, document review, interview and observation which revealed that the agency failed to ensure that “non-core” services were available and provided directly by hospice or under arrangement. The hospice did not have the following "non-core" services available for the provision of physical therapy by direct or contracted staff HSLG.14.D/L655]. The cumulative effect of these deficient practices may pose a risk to patient safety and has resulted in a Condition Level finding under CFR 418.70 Furnishing of Non-Core Services.

It is required that a written agreement with another organization or individual to furnish hospice care or services includes the scope of services to be provided, how Interdisciplinary Group (IDG) management oversight and coordination is provided, how communication with the IDG and hospice administration occurs, care provided only upon authorization of the hospice, and care delivered in accordance with patient’s plan of care. The hospice retains administrative and financial management responsibility, as well as the oversight of staff and the quality of care and services provided under arrangement. This standard was not met as evidenced by clinical record review, document review, interview and observation. In 1 of 1 (100%) clinical records reviewed in which the patient received services from another organization revealed that the agency did not ensure that there was a written agreement with the other agency that specified that the hospice retains oversight and responsibility for the care provided and the cost of those services. Document 1: The agency policy "Contractual Agreements" (LD.12) dated 11/1/2008 and reviewed and accepted 7/19/2023 read that the "Agency may provide care/services through another individual or entity and will have contractual arrangement/legally binding, written agreement...Agency maintains professional, financial, and administrative responsibility for arranged services...Agency retains responsibility for payment of these services." "Agency contracts ... will include ... the organization or individual who is responsible for ...the manner in which the contracted services are coordinated, supervised and evaluated by the hospice. The delineation of the role of the hospice and the contractor in ...client family assessment, and the interdisciplinary team case conference...the requirements for documentation...the procedure for determining charges and reimbursement and that hospice retains responsibility for payment for services." "Agency contracts...will include the following ...the type of care/service to be provided. Stipulation that services may be provided only with express authorization of the hospice. " "Agency will retain professional management responsibility for arranged services and ensure that they are furnished in a safe and effective manner ...in accordance with the client's plan of care." Then in the agency policy "Coordination of Care with Community Resources" (PC.22) dated 1/10/2013 and reviewed and accepted 7/19/2023 contained that "The agency will insure coordination of care, with outside resources that are providing care for the hospice patient. The hospice will collaborate, coordinate and advocate for the patient to achieve non-duplication of services and to facilitate the exchange of information, reporting, and coordination of client services. The hospice case manager will insure that this coordination of care is reflected in the clinical record." "The hospice staff will review the hospice plan of care, and the outside entities plan of care, to determine any duplication of service, and to ensure the patient receives the services the patient needs... The hospice staff and the outside entity will collaborate to facilitate a mutual plan of care for the hospice patient." "The hospice staff member will include the outside entity's care in the IDT comprehensive plan of care. The IDT will review these services, through the plan of care, in the IDT meeting. Clinical Record 3: The patient elected the hospice benefit on 7/18/2023. During the Home Visit observation on 10/4/2023, the patient reported that he was receiving regular Physical Therapy. A physician order dated 8/12/2023 documented "Physical Therapy to see patient to evaluate and treat. Therapy includes home exercise programs with safety precautions, ROM with strengthening, gait training, transfer training, balance activities and bed mobility. (Plus 2 PNR visits if necessary to complete therapy treatment plan) Discharge when goals are met or per patient request." There was no documented evidence that the hospice was supervising, coordinating, or covering the cost of the PT visits. Upon review of the clinical record and interview with the Director of Nursing (Staff 3) and the Administrator (Staff 1) on 10/4/2023 and 10/5/2023 it was identified that the patient was receiving Physical Therapy (PT) from a home health agency and not the hospice's contracted PT provider. The Administrator obtained the Home Health Certification and Plan of Care from the home health agency for the Home Health Certification period of 9/6/2023 - 11/4/2023 which included the Principal Diagnosis of Legal Blindness, and other diagnoses of unspecified abnormalities of gain and mobility, repeated falls, muscle weakness, and age-related debility. The orders for discipline and treatment were that the home health skilled nurse was to perform monthly visits for two months and for the home health PT to see the patient once the first week, then twice weekly for eight weeks. "Skilled nurse to perform comprehensive assessment ...and identify immediate care needs...skilled nurse (SN) to perform comprehensive assessment and admit to home heath...SN to assess and reconcile medications ...assess home and teach on safety and fall precautions, the home health plan of care ..." "Physical Therapy (PT) to assess functional status, home environment ...improve safety and functional independence...assess rehabilitation potential and determine need for gait training, safety precautions, pain management, strengthening/conditioning exercise, balance/coordination ..." It was confirmed during an interview with the Administrator (Staff 1) 10/4/2023 and 10/5/2023 that the patient was receiving Physical Therapy (PT) from a home health agency in which the hospice did not have a contract with nor was the hospice covering the cost of the services provided to the patient. Further, the Administrator stated that she believed that she met this standard/condition by the offer to the patient and family of Physical Therapy visits. She also stated that the offer of PT visits would be limited to a few visits only ("like 3 visits for safety"). Lastly, she said that if the patient/family declined that offer because they felt the patient required more services, then the hospice did not have to cover the cost of therapy if the family pursued physical therapy on their own by going to another PT provider. In an interview with the Administrator on 10/5/2023, the Administrator continued to state that she believed that she fulfilled this regulatory requirement by the initial offer of the PT visits alone and felt that ongoing PT visits would be considered by Medicare to be "rehabilitative" and aggressive treatment.

Each patient’s record includes, at a minimum physician orders. This standard was not met as evidenced by clinical record review and interview. In 1 of 5 (20%) clinical records reviewed revealed that the agency did not ensure that there was a physician order documented for a treatment/test. Clinical Record 5: The patent elected the hospice benefit on 7/12/2023. In the scanned documents was a report of a chest x-ray performed 8/24/2023 with the radiologist's impression: "Patchy opacity is seen in both lungs, mildly worse on the left side since previous." At the time of review, there was no order for a chest x-ray documented in the patient medical record. Personnel Record 3: It was confirmed during an interview with the Director of Nursing (DON) (Staff 3) on 10/5/2023 that the order was not in the clinical record at the time of review.