Kindness Care Home Health

“Discharge or Transfer Summary Content CFR(s): 484.58(b)(1) Standard: Discharge or transfer summary content. The HHA must send all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, to the receiving facility or health care practitioner to ensure the safe and effective transition of care. This Standard is not met as evidenced by: Based on record review, interview, and agency P&P review, the agency failed to ensure the discharge summary was provided to the patient’s physician after discharge for one of two sampled patients (Patient 2), creating the risk of not properly communicating the patient’s health care needs. Findings: The agency’s P&P titled Discharge Summary dated 4/2020 showed each patient discharged from the service shall have a written discharge summary filed in the clinical record. A copy of the discharge summary will be provided to the patient’s primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the organization within five business days of the patient’s discharge. Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services during the periods from 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. The Discharge Summary dated 8/21/24, showed the patient was discharged from home health services. Documentation showed the goals were met and maximum potential had reached. Documentation showed the patient needed supervision. Documentation showed the previous dressing was removed. Documentation showed the wound had scant serosanguineous drainage. Documentation showed the left foot ulcer was cleansed with normal saline, patted dry, covered with a conforming wrap, and secured tape. Documentation showed for the patient to follow-up with the physician as scheduled. The Task Details Discharge Summary dated 8/21/24, showed per the physician’s order, the wound was close. * However, there was no documented evidence a copy of the discharge summary was sent to the patient’s physician within five (5) business days of the patient’s discharge as per the agency’s P&P. On 10/2/24 at 1530 hours, an interview and concurrent record review was conducted with the DPCS. The DPCS stated after the SN visit on 8/21/24, the patient went to the physician’s office. She stated the physician stated the wound was close. She was informed and acknowledged the findings.”

“5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient’s immediate needs, but no later than 5 calendar days after the start of care. This Element is not met as evidenced by: Based on record review, interview, and agency P&P review, the agency failed to ensure the initial comprehensive assessments were completed in a timely manner, consistent with the patients’ immediate needs for two of two sampled patients (Patients 1 and 2), creating the risk of not identifying and addressing the care needs timely for these patients. Findings: The agency’s P&P titled Initial and Comprehensive Assessment dated 4/2020 showed a comprehensive patient assessment will be completed within five calendar days of the patient’s start of care. The agency’s P&P titled Wound Care (undated) showed it is the policy for the HHA to provide pressure ulcer and wound care in a manner commensurate with standards of practice. When a wound is initially identified the interdisciplinary team will be consulted and physician orders for treatment obtained. Initial documentation will include location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. 1. Review of Patient 1’s clinical record was initiated on 10/1/24. The clinical record showed the SOC was 7/30/24. The patient was certified for home health services during the period from 7/30/24 to 9/27/24. The start of care assessment dated 7/30/24, showed the patient had three stasis ulcers. Documentation showed three photographs of the patient’s stasis ulcers. The Wound Care Worksheet included wound #1 was on the patient’s left lower leg. Documentation showed the SN assessed the wound bed, drainage and amount. * However, for wound #1 (left lower leg), there was no documented evidence of the wound size and odor. * There was no information for the other two stasis ulcers, including the location, size, presence or absence of drainage, description of any drainage, and description of the surrounding tissue. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services during the periods from 3/20/24 to 5/18/24, 5/19/24 to7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. The start of care assessment dated 3/20/24, showed the patient had the left foot wound. However, the information for the wound bed was not completed. In addition, there was no documented evidence the patient’s external genitalia was assessed. On 10/2/24 at 1530 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings.”

“Last 5 days of every 60 days unless: CFR(s): 484.55(d)(1)(i,ii,iii) The last 5 days of every 60 days beginning with the start-of-care date, unless there is a- (i) Beneficiary elected transfer; (ii) Significant change in condition; or (iii) Discharge and return to the same HHA during the 60-day episode. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure the updated comprehensive assessments were completed in a timely manner on the last five days of every 60 days beginning with the start-of-care date for one of two sampled patients (Patient 2), creating the risk of not providing appropriate, consistent, and quality care to this patient. Findings: Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services during the periods from 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. The start of care assessment dated 3/20/24, showed the RN conducted the initial comprehensive assessment. The recertification assessment dated 5/23/24, for the period from 5/19/24 to 7/17/24, showed the RN conducted the visit. Documentation showed the patient had the left foot wound. * However, the information for the left foot wound bed and odor was not completed. There was no documented evidence the patient’s external genitalia was assessed. In addition, the SN did not conduct the assessment on the last five days of every 60 days beginning with the start-of-care date. The recertification assessment dated 7/18/24, for the period from 7/18/24 to 8/21/24, showed the RN conducted a visit. Documentation showed the patient had the left foot wound. * However, the information for the wound bed and odor was not completed. There was no documented evidence the patient’s external genitalia was assessed. In addition, the SN did not conduct the assessment on the last five days of every 60 days. On 10/2/24 at 1530 hours, an interview and concurrent closed clinical record review was conducted with the DPCS. She was informed and acknowledged the findings.”

“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 record review and interview, the agency failed to ensure the individualized POC was developed and included the required elements for two of two sampled patients (Patients 1 and 2). This failure created the risk of not providing necessary services to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 10/1/24. The clinical record showed the SOC was 7/30/24. The patient was certified for home health services during the period from 7/30/24 to 9/27/24. a. The start of care assessment dated 7/30/24, showed the patient had three stasis ulcers. The POC, for the certification period from 7/30/24 to 9/27/24, showed SN visits 1W (one time a week) for five weeks from 8/7/24 to 9/7/24. The POC showed the parameters when to notify the physician related to the patient’s temperature, pulse, respirations, and blood pressure. * However, the POC did not showed the patient’s diagnosis, wound care/treatment for the three stasis ulcers, SN frequency after 9/7/24, and to obtain the vital signs. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services during the periods from 3/20/24 to 5/18/24, 5/19/24 to7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. a. The start of care assessment dated 3/20/24, showed the RN conducted a visit. Documentation showed the RN conferenced with the HHA regarding SN visits 2W9. Documentation included the patient had a left foot ulcer to be cleansed with NS and patted dry, MediHoney (wound dressing) and Calcium alginate (wound dressing) to be applied, covered with a gauze, wrap with a conforming wrap, and secured with tape. * However, for the period 3/20/24 to 5/18/24, showed no documented evidence an individualized plan of care was developed to include the required elements which were all pertinent diagnoses; the patient’s mental, psychosocial, and cognitive status; the types of services, supplies, and equipment required; the frequency and duration of visits to be made; prognosis; rehabilitation potential; functional limitations; activities permitted; nutritional requirements; all medications and treatments; safety measures to protect against injury; 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; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; information related to any advanced directives; and any additional items the HHA or physician or allowed practitioner may choose to include. On 10/2/24 at 1530 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings.”

“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 the services and treatments were administered only as ordered by the physician for two of two sampled patients (Patients 1 and 2), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 10/1/24. The clinical record showed the SOC was 7/30/24. The patient was certified for home health services during the period from 7/30/24 to 9/27/24. The start of care assessment dated 7/30/24, showed the patient had three stasis ulcers. The recertification assessment dated 9/24/24, showed the patient had three venous ulcers to the right and left lower extremities. The SN notes dated 8/7, 8/14, 8/23, and 9/5/24, and the recertification assessment dated 9/24/24, showed the bilateral lower extremities wounds were cleansed with normal saline and patted dry with non-sterile gauze. * However, there was no documented evidence of a physician’s order for the treatment of bilateral lower extremities. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 10/3/24. The closed clinical record showed the SOC was 7/30/24. The patient received home health services from periods 3/20/24 to 5/18/24, 5/19/24 to7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. a. The start of care assessment dated 3/20/24, showed the RN conducted a visit. Documentation showed the SN conferenced with the HHA regarding SN visits 2W9. The SN notes showed the SN had conducted visits for the period from 3/20/24 to 5/18/24. * However, there was no documented evidence of a written physician’s order for the SN visits. Cross reference to G0574, example #2 b. The SN notes for the period from 3/20/24 to 5/18/24, showed the SN provided treatment for the patient’s left foot wound. However, there was no documented evidence of a physician’s order for the wound care. For example: The SN note dated 3/22/24, showed the patient left foot ulcer was cleansed with NS, patted dry, applied Medi Honey (wound dressing) and calcium alginate (wound dressing). c. The physician’s order dated 5/23/ 24, showed the patient was recertified to the HHA from 5/19/24 to 7/17/24. Documentation showed the patient needed SN visits 2W9 for wound care, using an aseptic technique, for the left foot ulcer to be cleansed with NS and patted dry. Medi Honey (wound dressing) and Calcium alginate (wound dressing) to be covered with a gauze, wrapped with a conforming wrap, and secured with tape. Some of the SN notes for the period 5/19/24 to 7/17/24, showed the SN provided wound care for the patient’s left foot with the application of Santyl (wound dressing). For example: The SN note dated 6/12/24, showed the patient had a left foot wound. Documentation showed the left foot ulcer was cleansed with normal saline and patted dry. Documentation showed the patient had Santyl and stated the physician wanted Santyl used on the wound. Documentation showed Santyl was applied, covered with gauze, wrapped with conforming wrap, and secured with tape. * However, there was no documented evidence of a physician’s order for the use of Santyl. d. The recertification assessment dated 7/18/24, showed the RN conducted a visit. Documentation showed the SN conferenced with the HHA regarding SN visits 2W9. The SN notes showed the SN had conducted the visits for the period from 7/18/24 to 8/21/24. * However, there was no documented evidence of a physician’ order for the SN visits. Cross reference to G 0588, example # 2.B e. The SN notes for the period from 7/18/24 to 8/21/24, showed the SN provided treatment for the patient’s left foot wound. For example: The SN note dated 7/24/24, showed the patient had left foot wound. Documentation showed the patient’s left foot ulcer was cleansed with normal saline and patted dry, Santyl was applied, covered with gauze, wrapped with conforming wrap, and secured with tape. However, there was no documented evidence of a physician’s order for the wound care. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings.”

“Verbal orders CFR(s): 484.60(b)(3)(4) (3) Verbal orders must be accepted only by personnel authorized to do so by applicable state laws and regulations and by the HHA’s internal policies. (4) When services are provided on the basis of a physician or allowed practitioner’s verbal orders, a nurse acting in accordance with state licensure requirements, or other qualified practitioner responsible for furnishing or supervising the ordered services, in accordance with state law and the HHA’s policies, must document the orders in the patient’s clinical record, and sign, date, and time the orders. Verbal orders must be authenticated and dated by the physician or allowed pracitioner in accordance with applicable state laws and regulations, as well as the HHA’s internal policies. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the verbal orders were signed and dated by the physician for two of two sampled patients (Patients 1 and 2), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: According to the California Code of Regulations, Title 22, Section 74701(a), no medication or treatment shall be given except on signed order of a person lawfully authorized to give such order. Such order may be given by telephone and shall be signed by the patient’s attending physician, dentist, podiatrist, or other licensed and legally authorized practitioner within his or her scope of practice within 30 working days. Findings: 1. Review of Patient 1’s clinical record was initiated on 10/1/24. The clinical record showed the SOC was 7/30/24. The patient was certified for home health services during the period from 7/30/24 to 9/27/24. The POC, for the certification period from 7/30/24 to 9/27/24, showed the RN obtained the verbal SOC on 7/30/24. The physician’s order dated 7/29/24, showed the patient was admitted to HHA. The order included SN evaluation and treat 1W6 (one time a week for six weeks). The physician’s order dated 8/5/23, showed 1W for five weeks (8/5/24 to 9/7/24). The above POC and physician’s order showed the sections for the physician’s signature and date. * However, there was no documented evidence of the physician’s signature and date. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services during the periods from 3/20/24 to 5/18/24, 5/19/24 to7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. The physician’s order dated 5/23/24, showed the patient was recertified for home health services. The order included for the patient needs, SN visits 2wk9 for wound care. * However, there was no documented evidence of the physician’s signature and the date. On 10/2/24 at 1530 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings.”

“Reviewed, revised by physician every 60 days CFR(s): 484.60(c)(1) The individualized plan of care must be reviewed and revised by the physician or allowed practitioner who is responsible for the home health plan of care and the HHA as frequently as the patient’s condition or needs require, but no less frequently than once every 60 days, beginning with the start of care date. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the individualized plan of care was reviewed and revised by the physician for two of two sampled patients (Patients 1 and 2), creating the risk of not providing necessary care and services to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 10/1/24. The clinical record showed the SOC was 7/30/24. The patient was certified for home health services during the period from 7/30/24 to 9/27/24. The recertification assessment dated 9/24/24, showed the RN had conducted a visit. Documentation showed a conference with the physician, to continue the wound care 2W4 (two visits a week for four weeks). Documentation showed the physician was contacted regarding the assessment findings and medication verification. Documentation showed the order changes were obtained and to continue the plan of care. * However, there was no documented evidence an individualized plan of care was revised for this patient for the period 9/28/24 to 11/26/24. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services from periods 3/20/24 to 5/18/24, 5/19/24 to 7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. a. The recertification assessment dated 5/23/24, showed the patient had a left foot ulcer to be cleansed with NS and patted dry, Medi Honey (wound dressing) and Calcium alginate (wound dressing) to be applied, covered with a gauze, wrap with a conforming wrap, and secured with tape. Documentation showed the RN had conferenced with the HHA regarding the SN visits 2W9. The physician’s order dated 05/23/24, showed the patient was recertified to the HHA from 5/19/2024 to 7/17/2024. Documentation showed the patient needed SN visits 2W9 for the wound care, using aseptic technique, for the left foot ulcer to be cleansed with NS and patted dry, applied Medi Honey and Calcium alginate, covered with a gauze, wrapped with a conforming wrap, and secured with tape. Documentation showed the patient was unable to perform wound care due to complexity of wound, location, size of wound, poor manual dexterity, forgetful, and knowledge deficit. Documentation showed no skilled/caregiver to perform wound care. Documentation showed no fall safety discussed and reinforced. Documentation showed the patient stated he had difficulty walking and had been very tired and had no care giver. * However, some of the requirements in an individualized plan of care was not reviewed and revised for the period from 5/19/24 to7/17/24. For example, there was no documented evidence the plan of care included the patient’s mental, psychosocial, and cognitive status; supplies, and equipment required; prognosis; rehabilitation potential; functional limitations; activities permitted; nutritional requirements; medications; safety measures to protect against injury; 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; patient and caregiver education and training to facilitate timely discharge; patient-specific interventions and education; measurable outcomes and goals identified by the HHA and the patient; and information related to any advanced directives. b. The recertification assessment dated 7/18/24, showed the RN had conducted a visit. Documentation showed the RN had conferenced with the HHA regarding SN visits 2W9. Documentation showed the patient had a left foot ulcer to be cleansed with NS and patted dry, applied with Medi Honey (wound dressing) and Calcium alginate, covered with a gauze, wrapped with a conforming wrap, and secured with tape. * However, there was no documented evidence an individualized plan of care was reviewed and revised for this patient for the period 7/18/24 to 8/21/24. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings.”

“Communication with all physicians CFR(s): 484.60(d)(1) Standard: Coordination of Care. The HHA must: (1) Assure communication with all physicians or allowed practitioners involved in the plan of care. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure the effective communication with the physician for two of two sampled patients (Patients 1and 2), creating the risk of not providing necessary care and services to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 10/1/24. The clinical record showed the SOC was 7/30/24. The patient was certified for home health services during the period from 7/30/24 to 9/27/24. The start of care assessment dated 7/30/24, showed the patient had three stasis ulcers. The POC, for the certification period from 7/30/24 to 9/27/24, showed SN visits 1W for five weeks from 8/7/24 to 9/7/24. The Missed Visit Form dated 8/27/24, showed the patient had requested to reschedule for next week due to other appointments. Documentation showed the supervisor was notified. * However, there was no documented evidence the physician was notified of the missed visit. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services from periods 3/20/24 to 5/18/24, 5/19/24 to7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. a. The start of care assessment dated 3/20/24, showed the RN conducted a visit. Documentation showed the patient had a left foot wound, measuring 2 cm (length) x 1.5 cm (width) x 0.4 cm (depth), with a small amount of serosanguineous drainage and a foul odor present. Documentation showed the SN had conferenced with the HHA regarding SN visits 2W9. * However, there was no documented evidence the SN notified the physician of the RN’s start of care assessment including the patient’s wound assessment. b. The SN note dated 3/29/24, showed under the narrative section of the note, the patient’s wound appear to have more slough today (3/29/24) and an increase of brownish drainage. Another section of the note showed the wound had serosanguineous drainage. * However, there was no documented evidence the SN had informed the physician about the presence of more slough in the wound. On 10/2/24 at 1530 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings.”

“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 interview, record review, and agency P&P review, the agency failed to ensure the effective integration of services related to wound care management and pain assessment for two of two sampled patients (Patients 1 and 2), creating the risk of not providing appropriate, consistent, and quality care to these patients. Findings: 1. Review of Patient 1’s clinical record was initiated on 10/1/24. The clinical record showed the SOC was 7/30/24. The patient was certified for home health services during the period from 7/30/24 to 9/27/24. The start of care assessment dated 7/30/24, showed the patient had three stasis ulcers. The POC, for the certification period from 7/30/24 to 9/27/24, showed SN visits 1W for five weeks from 8/7/24 to 9/7/24. The POC showed SN to assess pain level, effectiveness of pain medication, and current management therapy every visit. a. The Task Detail SN Wound Care note dated 8/23/24, showed the patient needed wound care doctor. The patient had seen a wound care doctor before, but the drive was hard for the patient as the patient experienced edema and pain to both lower extremities while sitting. Documentation showed an authorization number for the wound doctor “processed.” On 10/2/24 at 1513 hours, an interview was conducted with the DPCS. She stated the insurance company processed the authorization for the wound care “doctor.” The DPCS stated the process would be the insurance company to send the authorization to the wound “doctor” and the wound “doctor” would go to the patient’s house. * However, there was no documented evidence of care coordination between the HHA and wound care “doctor.” b. Review of the clinical record showed some of the SN notes were inaccurate related to the pain assessments. For example: The SN note dated 8/7/24, showed under the section pain assessment, the patient had a pain level of 5 (on a 0-10 pain scale, with 0= no pain and 10=worst pain). The narrative section showed the patient had a pain level of 6 to bilateral lower extremities. The SN note date 8/23/24, showed the pain assessment of a pain level of 5. The narrative section showed the patient had a pain level of 4 to the bilateral lower extremities. The SN failed to ensure accurate pain assessments were documented in the clinical record for use to integrate services when needed. On 10/2/24 at 1513 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings. 2. The agency’s P&P titled Wound Care undated showed it is the policy for the HHA to provide pressure ulcer and wound care in a manner commensurate with standards of practice. When a wound is initially identified the interdisciplinary team will be consulted and physician orders for treatment obtained. Initial documentation will include location, size, stage, depth, presence or absence of drainage, description of any drainage, description of surrounding tissue and any discomfort to the patient. The skilled nurse will observe the wound weekly and will document according to the individualized plan of care and the patient’s specific goal including: a. location, description of drainage, wound surface, and surrounding tissue b. related factors: vital signs, presence of elevated temperature, discomfort related to wound c. interventions, instructions, and patient’s response to - wound care/treatment - administration of medications related to wound management, - use of special mattresses or devices related to management of wound - any other interventions related to management of wound d. any communication to the physician, patient’s family, hospice staff, nursing facility staff, and/or physician e. changes in patient’s acuity level f. related factors Review of Patient 2’s closed clinical record was initiated on 10/1/24. The closed clinical record showed the SOC was 3/20/24. The patient received home health services from the periods from 3/20/24 to 5/18/24, 5/19/24 to7/17/24, and 7/18/24 to 8/21/24. The patient was discharged from the HHA on 8/21/24. The SN notes showed the patient’s left foot ulcer was not consistently observed and documented weekly for the description of drainage and wound surface as per the agency’s Wound Care P&P to ensure accurate and current information would be integrated with other disciplines. For example: a. The SN note dated 3/22/24, showed the patient had a left foot ulcer with a size of 2 cm x 1.5 cm x 0.4 cm. The wound bed was greenish with a small amount of serosanguineous drainage present. Documentation showed there was a foul odor. However, the documentation also showed the wound status was close, which was not consistent. b. The SN note dated 3/29/24, showed under the narrative section of the note, the patient’s wound appeared to have more slough (today) and an increase of brownish drainage. Another section of the note showed the wound had serosanguinous drainage, wherein the assessment for the wound drainage was not consistent. The SN failed to ensure accurate wound assessments were documented in the clinical record for use to integrate services when needed. On 10/2/24 at 1530 hours, an interview and concurrent record review was conducted with the DPCS. She was informed and acknowledged the findings.”