Canyon Home Care

“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 interview, and record review, the agency failed to ensure the individualized Plan of Care included complete orders for interventions, treatments, or medications in 2 of 12 current patient records reviewed (Patients #1 and #9). This deficiency was cited previously during a federal certification survey 2/3/21. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include: AGENCY POLICY: According to the agency policy titled “PICC (peripherally inserted central catheter) line dressing change” unknown date read in pertinent parts; “Inspect catheter and hub for any kinked or weakened areas. Note length of catheter exposed” 1. The clinical record for Patient #9 was reviewed on 1/24/24. Review of the plan of care for the certification period of 12/21/23 to 2/18/24 revealed a start of care date of 12/21/23; diagnoses included infection/inflammatory reaction due to internal right knee prosthetic, presence of right artificial knee joint, chronic combined systolic and diastolic heart failure, dysphagia and cardiomyopathy. Plan of care orders included skilled nursing (SN) services once a week for eight weeks for assessment of lab values, PICC line dressing changes, administer analgesics as prescribed by the MD and draw blood for labs via venous access device. a) The agency failed to ensure the plan of care for Patient #9 included PICC line measurements. Review of Patient #9’s clinical record revealed the agency had orders in the plan of care for PICC line dressing changes. Specifically the orders on the plan of care for Patient #9 regarding PICC line dressing changes read as follows; “weekly PICC line dressing changes.” There was no further information in the plan of care for Patient #9 regarding the PICC line including length of catheter or the location of the PICC line for the dressing change. Review of SN visit notes dated 1/4/24 and 1/11/24 revealed there was no documentation of the PICC line measurements. During an interview on 1/25/24 at 11:57 a.m., registered nurse (RN) #11 stated she did not do measurements on the PICC line, instead stating the agency used a stat lock and eyeballed the measurements. During the same interview the director of nursing (DON) stated the agency had a policy regarding PICC line dressing changes and the SNs were supposed to follow the policy. Review of the policy stated the length of the catheter was supposed to be measured. However the agency did not note the length of the catheter and the plan of care failed to have specific measurements regarding the length of the catheter as well. During an interview on 1/25/24 at 12:53 p.m., the DON stated the agency typically only wrote PICC line dressing change on the plan of care and did not include the location of the PICC line, or what the agency used to ensure the PICC line did not migrate. 2. The clinical record for Patient #1 was reviewed on 1/23/24. Review of the plan of care for the certification period of 11/27/23 to 1/25/24 revealed a start of care date of 12/2/22; diagnoses included encounter for fitting and adjustment of urinary device, encounter for attention to cystostomy and quadriplegia. Plan of care orders included SN services once every three weeks and five as needed visits for assessment of signs and symptoms of urinary tract infection, assessment for skin excoriation, breakdown, friction, shearing or pressure areas and changing of foley catheter as ordered; certified nursing assistant (CNA) services three times per week for nine weeks for assistance with activities of daily living. a) The agency failed to include catheter size and balloon size in Patient #1’s plan of care. Review of Patient #1’s clinical record revealed Patient #1 was to receive a new catheter every three weeks. However the plan of care did not specify the size of the catheter or the amount of liquid in the balloon. Review of SN visit notes on 12/8/23, 12/29/23 and 1/19/24 revealed RN #6 documented she used a 24 french catheter with a 10 milliliter (mL) balloon on all three of the visits. During an interview on 1/25/24 at 10:27 a.m., RN #6 stated she had taken over the care of Patient #1 from a different nurse. RN #6 also stated the size of the catheter and the balloon were in the plan of care and was also informed by the DON what size to use, however record review failed to show the size of the catheter and balloon. During an interview on 1/25/24 at 11:15 a.m., the DON agreed the plan of care for Patient #1 was missing information regarding the size of the catheter and balloon.”

“Provide services in the plan of care CFR(s): 484.75(b)(3) Providing services that are ordered by the physician or allowed practitioner as indicated 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 patient received care in conformance with physician’s orders and as indicated in the plan of care for 2 of 4 active patient records reviewed who received wound care (Patients #6 and #7). Findings include: AGENCY POLICY According to an agency policy reviewed on 1/11/23 and titled, Medication And Treatment, (read in pertinent parts): “Medications or skilled treatments shall be administered only by licensed personnel to comply with signed orders from a person lawfully authorized to give the order. This order may be given over the telephone but shall be subsequently signed by the person giving the order within a timely manner. Unsigned orders will be resent to the physician and ongoing coordination with the physician’s office will occur in order to receive unsigned orders.” According to an agency policy reviewed on 1/11/22 and titled, Wound/Ulcer Management, (read in pertinent parts): “It is essential for the agency to obtain the necessary information about the patient’s condition and wound/ulcer status prior to the initial visit. This information may be obtained through an on-site visit to the patient if he/she is in an institution (e.g. hospital, nursing home, skilled nursing facility), by talking to the discharge planner, or by asking the referral source when the referral information is obtained.” 1. The clinical record for Patient #6 was reviewed on 1/23/24. Review of the plan of care for the certification period 12/18/23 to 2/15/24 revealed a start of care date of 12/18/23; diagnoses included pancytopenia, atrial fibrillation, hypertensive heart and kidney disease, heart failure, type two diabetes mellitus with diabetic chronic kidney disease, anemia, pulmonary hypertension, gout, gastro-esophageal reflux disease, spinal stenosis, cognitive communication deficit, localized edema, muscle weakness, history of falling, and presence of cardiac pacemaker. Plan of care orders included: physical therapy (PT) to assess and evaluate and one time a week for two weeks and two times a week for seven weeks to establish/upgrade a home exercise program (HEP)/walking program and gait training; occupational therapy (OT) to assess and evaluate and one time a week for 8 weeks for activities of daily living (ADL) training, education in HEP, education to patient/caregiver on safety awareness, energy conservation techniques, therapeutic exercise, and transfer training; speech therapy (ST) to assess and evaluate; and home health aide (HHA) one time a week for eight weeks for assistance with ADL, recognize and report any changes in patient’s skin condition, document bowel movements (BM), report to registered nurse (RN) if no BM in three days and assess vital signs and report pain to RN. a) The agency failed to ensure the RN had orders to provide wound care for Patient #6. Review of a communication note dated 1/12/24 and time stamped 8:31 a.m., documented by the alternate administrator stated RN #12 reported she received a phone call from Patient #6’s wife on 1/11/24. Patient #6’s wife informed the agency Patient #6 hit his left arm after his shower and sustained a wound on his left upper extremity. Patient #6’s wife reported she applied antibiotic ointment and covered the wound and did not require care that evening, but requested a nurse to come and assess the wound and provide care the next day. Review of the clinical record revealed a verbal order received at 9:19 a.m. on 1/12/24 for skilled nursing (SN) to assess and evaluate Patient #6. Further review of the record failed to reveal any wound care instructions for 1/12/24 from Patient #6’s primary care physician (PCP) and/or from the emergency room department (ED). Review of a SN dated 1/12/24 revealed RN #6 documented Patient #6 had bruising and edema on his left arm with two skin tears. RN #6 documented Patient #6 reported he fell two times and went to the ED after the first fall and the ED department provided care to the two wounds on Patient #6’s left arm including wrapping his arm in Coban (a type of wound care dressing that adheres to itself, protects primary dressings, and provides pressure). RN #6 documented she removed the Coban and assessed Patient #6’s two left arm wounds. RN #6 “applied steri-strips (a thin adhesive bandage often used by surgeons as a backup to dissolved stitches or after regular stitches are removed) to skin flap on the forearm. Bandage over top of wound. Cleaned and redressed larger wound on elbow with super absorbent pad and kerlix (rolled gauze) wrapped around.” RN #6 also documented “Called PCP after the visit and left a message for order.” During an interview on 1/24/24 at 12:17 p.m., RN #6 stated the agency’s expectation was she was to call a physician to obtain orders prior to providing care. RN #6 stated she received orders to go and assess Patient #6 as he had sustained two wounds to his left arm. RN #6 stated she did not receive specific instructions from Patient #6’s PCP on how to care for Patient #6’s two left arm wounds nor was there instructions in Patient #6’s home from his ED visit for his two left arm wounds. RN #6 acknowledged she provided care to Patient #6’s two left upper extremity wounds and then called Patient #6’s PCP for permission for the wound care she had already rendered. b. The agency failed to ensure the RN followed orders for the wound care provided to Patient #6. Review of the clinical record revealed a verbal order on 1/16/24 from Patient #6’s PCP which stated, SN two times a week for five weeks and wound care as follows: cleanse wound with wound cleanser and pat dry; apply steri-strips to skin flap when needed; apply super absorbent bandage and wrap with kerlix; secure with tape. Review of the clinical record failed to reveal any further wound care orders for Patient #6’s left upper extremity wounds. Review of a SN note dated 1/16/24 revealed RN #6 documented under “interventions provided” RN #6 performed the following wound care to Patient #6’s left forearm wound: cleanse with wound cleanser and pat dry; apply steri-strips to skin flap when needed; apply foam border dressing. Review of the clinical record failed to show a physician order to apply a foam border dressing. Review of a SN note dated 1/19/24 revealed RN #6 documented under “interventions provided” RN #6 performed the following wound care: to Patient #6’s left elbow wound - cleanse with wound cleanser and pat dry, apply steri-strips to skin flap when needed, apply super absorbent bandage, and wrap with kerlix and secure with tape; and to Patient #6’s left forearm wound - cleanse with wound cleanser and pat dry, apply steri-strips to skin flap when needed, apply foam border dressing. In the narrative section of the note, RN #6 documented Patient #6’s blood pressure (BP) was 160/82 and RN #6 called Patient #6’s PCP after the visit where she left a message with Patient #6’s PCP office requesting a call back to report Patient #6’s elevated BP. RN #6 also documented Patient #6’s wound care was done according to order and RN #6 applied a foam border dressing to both wounds. RN #6 documented she did not wrap either wound with kerlix (as was ordered) because Patient #6 refused. Review of the clinical record failed to show RN #6 had communicated to Patient #6’s PCP Patient #6’s refusal of the kerlix wrap or an order to apply a foam border dressing. Review of a SN note dated 1/22/24 revealed RN #6 documented under the “interventions provided” she performed the following wound care to Patient #6’s left forearm wound: cleanse with wound cleanser and pat dry; apply steri-strips to skin flap when needed; apply foam border dressing. Review of the clinical record failed to show a physician order to apply a foam border dressing. During an interview on 1/24/24 at 12:23 p.m., RN #6 stated after she provided wound care to Patient #6’s two left arm wounds on 1/12/24 she attempted to reach Patient #6’s PCP to obtain orders for the wound care she had already provided. RN #6 stated she had to leave a message and did not speak to Patient #6’s PCP office until the morning of 1/16/24 where she received the verbal order documented in Patient #6 chart which stated to cleanse the wound, apply steri-strips as needed, apply a super absorbent dressing, wrap with kerlix and secure with tape. RN #6 stated this verbal order was for both of Patient #6’s left upper extremity wounds. RN #6 stated on 1/16/24 and 1/22/24 she applied a foam border dressing to Patient #6 left forearm wound and on 1/19/24 she applied a foam border dressing to both of Patient #6’s left arm wounds. RN #6 stated Patient #6 did not like the kerlix as it slipped down his arm so she changed the wound care provided based on Patient #6’s preference. RN #6 stated she did not call Patient #6’s PCP to inform him at any time, including when she placed the phone call to Patient #6’s PCP on 1/19/24 regarding Patient #6’s elevated BP, of Patient #6’s dislike of the superabsorbent pad with kerlix dressing and her decision to switch to using a foam border dressing instead. RN #6 acknowledged she should have called Patient #6’s PCP to receive orders to change Patient #6’s wound care and she would ensure to call a patient’s physician in the future to obtain orders prior to providing care to a patient. 2. The clinical record for Patient #7 was reviewed on 1/24/24. Review of the plan of care for the certification period 1/4/24 to 3/3/24 revealed a start of care date of 1/4/24; diagnoses included cellulitis of left lower limb, venous insufficiency, mixed hyperlipidemia, hypertension, anxiety, chronic pain, gastro-esophageal reflux disease, cervical disc disorder, hypothyroidism, angina pectoris, abnormal findings of the lung, low back pain, urinary and fecal incontinence. Plan of care orders included: SN to assess and evaluate for signs and symptoms of wound infection, assessment and management of urinary incontinence, assess pain, assess skin integrity and perform wound care; and PT to assess and evaluate. Further review of the clinical record revealed a verbal order obtained on 1/17/24 at 11:14 a.m. which stated the following: SN one time a week for one week and three times a week for six weeks with five as needed (PRN) visits to include wound care on left lower extremity. The wound care to the left lower extremity order was as follows: clean and pat dry the wound; apply barrier cream around the wound and hydrogel (a gel used for dry to mildly draining wound which can also assist with removing dead cells which have accumulated in the wound bed) in the wound; cover wound with adaptic (a non-adhering wound dressing which protects regenerating tissue in the wound bed), wrap the leg with an Unna boot (a semirigid paste bandage), kerlix and Coban. Review of the clinical record showed Patient #7 transferred to the hospital and was admitted on 1/6/24 for care and surgical treatment of a small bowel obstruction. Review of hospital discharge records faxed to the agency on 1/15/24 showed Patient #7 was in the hospital from 1/6/24 to 1/12/24 and underwent a diagnostic laparoscopy converted to open small bowel resection. The discharge instructions from the hospital included orders for Patient #7 to receive SN, PT and OT with SN for medication management and wound care. The discharge instructions failed to provide instructions on the specific wound care Patient #7 was to receive. a. The agency failed to ensure the RN obtained an order for wound care provided to Patient #7’s abdominal incision. Review of a resumption of care assessment on 1/17/24 revealed RN #6 documented in the “interventions provided” Patient #7 had a lower medial abdomen midline surgical incision which measured 8.5 centimeters (cm) by 0.2 cm and had copious amounts of sanguineous (drainage which contains blood) drainage. RN #6 documented she cleaned this wound with sterile saline, covered the wound with gauze pads, and secured the gauze with tape. In the narrative section of the note, RN #6 documented Patient #7 had a large midline incision of her abdomen and RN #6 changed the dressing as she observed blood on the older bandage. RN #6 stated Patient #7 reported she had gone to the ED on 1/16/24 due to her abdominal incision developing a hematoma (a bruise with pooling of blood) which ruptured. RN #6 documented Patient #7 reported the hospital drained the blood from the wound and dressed the wound with an abdominal pad (a large absorbent pad). RN #6 documented she provided care to Patient #7’s lower extremity wounds and called Patient #7’s PCP to inform him of a new wound Patient #7 developed on her left lower extremity and for orders for wound care. Review of Patient #7’s record failed to reveal an order for wound care to Patient #7’s abdominal incision. During a home visit on 1/24/24 at approximately 3:00 p.m., Patient #7 confirmed she was in the hospital from approximately 1/6/24 until 1/12/24 for bowel surgery and returned to the ED on 1/16/24 for care due to bleeding at her abdominal incision. During an interview on 1/24/24 at 12:53 p.m., RN #6 acknowledged she provided wound care to Patient #7’s abdominal incision without having orders. RN #6 stated when she completed Patient #7’s resumption of care assessment and visit on 1/17/24, she observed Patient #7’s abdominal incision to have sanguineous drainage. RN #6 stated she did not have any orders to change Patient #7’s abdominal incision dressing and when she called Patient #7’s PCP during the visit she obtained orders only for wound care to Patient #7’s left lower extremity wounds. RN #6 stated Patient #7 did not provide her with any orders from her ED visit on 1/16/24 for care of Patient #7’s abdominal incision nor did the agency provide any orders for Patient #7’s abdominal incision from Patient #7’s hospital admission from 1/6/24 to 1/12/24 or ED visit on 1/16/24. RN #6 stated she completed the wound care to Patient #7’s abdominal incision as Patient #7’s incision was draining and the dressing was wet from the drainage. RN #6 stated she should have requested orders for care she provided to Patient #7’s abdominal incision from either Patient #7’s PCP and/or surgeon prior to providing the wound care she rendered on 1/17/24 to Patient #7’s abdominal incision. 3. During an interview on 1/24/24 at 1:11 p.m., the director of nursing (DON) stated the agency expected a SN to call a physician to obtain orders prior to providing any treatments and the agency expected the SN to call a physician to obtain orders if the ordered treatment needed to be changed. The DON acknowledged Patient #6’s clinical record failed to show an order to change Patient #6’s wound care from a super absorbent dressing and kerlix to a foam border dressing. Employee #13 stated RN #6 provided first aid to Patient #7 at her 1/17/24 visit, and thus, did not need an order for the wound care she provided to Patient #7 on 1/17/24. Employee #13 acknowledged Patient #7’s abdominal wound was from a surgical incision and not an accident. Employee #13 also acknowledged Patient #7 had received initial care for her surgical abdominal incision in the hospital after the surgery as well as at a 1/16/24 ED visit and the agency failed to have orders on what wound care to provide the abdominal incision from either the hospital or the ED visit. The DON and Employee #13 both stated when a SN found a patient to have a new wound or incision, the SN should assess the wound/incision and then call the physician to obtain orders for care. Employee #13 stated the agency would be providing an agency wide training to reeducate all of their providers on the importance of calling a physician to obtain orders prior to providing care and/or changing the care provided to a patient.”

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure clinical records contained accurate documentation of pertinent past and current findings in accordance with accepted professional standards for 1 of 12 active patients’ records reviewed (Patient #5). Findings include: 1. The clinical record for Patient #5 was reviewed on 1/23/24. The face sheet in the record revealed a start of care date of 1/14/24. Review of the record failed to show a plan of care had been created for Patient #5 by the review date. Review of a referral order for Patient #5 revealed skilled nursing (SN), physical therapy (PT), occupational therapy (OT) and speech therapy (ST) to assess and evaluate. Review of a verbal order received at 1:15 p.m. on 1/16/24 showed Patient #5 was to receive SN two times a week for eight weeks for medication management, education and 16 French 10 cubic centimeters (cc) foley catheter changes every 30 days with three as needed (PRN) visits effective 1/16/24. Review of a verbal order received at 2:44 p.m. on 1/16/24 showed Patient #5 was to receive ST one time a week for eight weeks effective 1/21/24. Review of a verbal order received at 2:25 p.m. on 1/17/24 showed Patient #5 was to receive PT two times a week for seven weeks effective 1/21/24. Review of a verbal order received at 3:00 p.m. on 1/23/24 showed Patient #5’s SN frequency changed to one time a month for two months with 5 PRN visits effective 2/1/24. Review of the clinical record failed to show any further orders for Patient #5. a. Clinical record review revealed the agency failed to ensure the registered nurse (RN) documented accurate and complete information regarding a certified nursing assistant (CNA) supervisory note despite Patient #5 not receiving CNA services. Review of a SN communication note dated 1/15/24 at 2:46 p.m. showed RN #14 documented Patient #5 would benefit from a CNA to come two times a week to assist Patient #5 with showers and activities of daily living and to encourage Patient #5 to be as independent in his care as possible. Review of Patient #5’s record showed a CNA care plan was created which showed Patient #5 should receive care from the CNA with goals as follows: promote healthful environment, optimal independence, promote skin integrity, patient’s personal care needs will be met and promote safe and personal care and hygiene with goals initiated on 1/14/24 and resolved on 1/23/24. The interventions the CNA was to perform were as follows: ambulation using an assistive device, assistance with transfers and exercise program, up in chair/wheelchair, catheter care, assistance with changing incontinence products, empty foley catheter, make patient’s bed, assistance with dressing, assistance with bathing, encourage patient to wear glasses/hearing aides, may trim or file any long or uneven fingernails, oral care, shampoo hair, assistance with shaving, fall precautions and standard precautions all to be initiated as of 1/14/24 and all resolved as of 1/23/24. Further review of Patient #5’s record failed to show an order was obtained to initiate CNA services or documentation a CNA provided Patient #5 with care. Review of a SN note on 1/17/24 showed RN #6 documented a CNA supervisory visit for CNA #7. RN #6 documented she found CNA #7 to: follow the CNA care plan for task provided to Patient #5; maintain an open communication process with the patient, caregivers, family and representative; demonstrate competency with assigned tasks, document task provided appropriately; provide personal care; Patient #5 satisfied with care provided by CNA #7; complied with infection prevention and control policies/procedures; reported changes in Patient #5’s condition; and honored Patient #5’s rights. Review of a SN note narrative for 1/22/24 visit created on 1/23/24 at 5:29 p.m. by RN #6 showed RN #6 discussed CNA services for Patient #5 with Patient #5’s wife and Patient #5’s wife refused CNA services for Patient #5. During a home visit on 1/24/24 at approximately 10:00 a.m., Patient #5’s wife confirmed the agency offered CNA services for Patient #5, but she declined these services as she was a nurse and was capable of assisting Patient #5 with his personal care needs. During an interview on 1/24/24 at 12:34 p.m., RN #6 stated she was Patient #5’s RN case manager, but stated she did not complete his initial visit on 1/14/24. RN #6 stated when she reviewed Patient #5’s record prior to providing him care on her initial visit on 1/17/24, she observed a CNA care plan had been created for Patient #7 by RN #14, thus RN #6 thought she needed to complete a CNA supervisory visit for Patient #5. RN #6 acknowledged she filled the supervisory visit portion of her 1/17/24 note out without confirming Patient #5 was receiving CNA services; without checking CNA documentation to ensure it was done accurately, or without consulting with Patient #5 or his wife to see if they were happy with the CNA care as she documented in the supervisory visit portion of her SN note. RN #6 stated she found out at her 1/19/24 visit with Patient #5, Patient #5’s wife had refused CNA services and Patient #5 never received CNA care from the agency for care provided on and after the 1/14/24 start of care date. RN #6 stated her assumption Patient #5 was receiving CNA care and inaccurately filling out a CNA supervisory visit for Patient #5 was a problem. During an interview on 1/24/24 1:34 p.m., the director of nursing (DON) reviewed Patient #5’s clinical record. The DON stated RN #14 completed the start of care SN for Patient #5 and recommended CNA services for Patient #5. RN #14 created a CNA care plan, but never obtained an order for CNA services. The DON confirmed Patient #5 had not received any CNA care since his start of care on 1/14/24, and expressed dismay over RN #6 documentation of a CNA supervisory visit for care never received by Patient #5.”

“Onsite supervisory visit every 14 days CFR(s): 484.80(h)(1)(i) If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient’s plan of care, and the written patient care instructions described in §484.80(g), must make an onsite visit to the patient’s home no less frequently than every 14 days. The home health aide does not have to be present during this visit. This Element is not met as evidenced by: Based on interview and record review, the agency failed to ensure a registered nurse (RN) or other appropriate skilled professional familiar with the patient, the patient’s plan of care and the written patient care instructions made an onsite visit to the patient’s home no less frequently than every 14 days to conduct certified nursing aide (CNA) supervision for 1 of 5 patients receiving skilled care and HCA services (Patient #1). Findings include: AGENCY POLICY According the agency policy titled “Clinical supervision of Home Health Aide” dated 1/11/2023, read in pertinent parts; “A supervisory visit to the patient’s home by an RN no less frequently than every 14 days as required if Patient receives skilled nursing care.” 1. The clinical record for Patient #1 was reviewed on 1/23/24. Review of the plan of care for the certification period of 11/27/23 to 1/25/24 revealed a start of care date of 12/2/22; diagnoses included encounter for fitting and adjustment of urinary device, encounter for attention to cystostomy and quadriplegia. Plan of care orders included skilled nursing (SN) services once every three weeks and five as needed visits for assessment of signs and symptoms of urinary tract infection, assessment for skin excoriation, breakdown, friction, shearing or pressure areas and changing of foley catheter as ordered; CNA services three times per week for nine weeks for assistance with activities of daily living. a) The RN failed to conduct onsite visits to supervise the CNA no less frequently than every 14 days as required. Review of Patient #1’s clinical record revealed RN #6 provided onsite supervisory visits three times between 11/27/23 and 1/24/24 which occurred on 12/8/23, 12/29/23 and 1/19/24. During an interview on 1/25/24 at 11:15 a.m., the director of nursing (DON) presented three additional aide supervisory visit forms which were completed by the DON on 12/6/23, 12/20/23, and 1/12/24 remotely. The DON stated she believed the agency was still under a COVID-19 waiver which allowed telephone supervisory visits for the 14 day supervisory visits. After reviewing the policies, the DON stated the agency no longer had a COVID-19 waiver for supervisory visits. The DON acknowledged the agency had failed to do onsite supervisory visits every 14 days for Patient #1.”