Sunny Brook Home Care

“EP Training Program CFR(s): 484.102(d)(1) §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: Based on review of the agency’s emergency preparedness plan/policies and agency staff interview, the agency failed to ensure training in emergency preparedness to all existing staff consistent with their expected roles at the time of orientation and every other year thereafter for all staff. Lack of emergency preparedness training for staff puts patients at risk should an emergency situation arise and staff would be needed to assist patients to ensure patient safety. Findings include: During an interview on 2/7/24 at 2:15 PM, Administrator reported inability to locate documentation of any emergency preparedness training for any staff since the last survey in 2021. No training has been completed over the past year. During an interview on 2/8/24 at 10:01 AM, Administrator confirmed no other information available. The agency failed to ensure all staff completed initial and biannual training in emergency preparedness as required by regulation. The surveyor reviewed the above stated findings with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.”

“Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This Standard is not met as evidenced by: Based on clinical record review and agency staff interview, the agency failed to ensure electronic signatures included staff credentials for 3 of 7 sampled patients (Patients #1, #4 and #6). Failure to maintain appropriately authenticated electronic signatures risked patients receiving services from inappropriate staff. 3. Patient #1 had a start of care date of 12/19/23. Clinical record review revealed the following: a. The initial comprehensive assessment, dated 12/19/23, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. b. A skilled nursing visit note, dated 12/27/24, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. c. Missed visit notification notes for the dates of 1/3/24, and 1/10/224 were marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents. The surveyor reviewed the above findings with the Administrator and Clinical Manager. No additional information provided prior to the end of the survey. Findings include: During an interview on 2/7/24 at 3:10 PM, the Administrator reported she was responsible for adding staff credentials to the electronic medical record signature. She would review and see why credentials are not showing for the new staff. 1. Patient #4 had a start of care date of 2/17/2020. Clinical record review revealed the following: a. The Plans of Care, dated 9/29/23 to 11/27/23, 11/28/23 to 1/26/24 and 1/27/24 to 3/26/24, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. b. Interim physician order, dated 1/15/24, for resumption of care orders, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. c. Resumption of Care assessment note, dated 1/15/24, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. d. Skilled nursing visit notes, dated 12/11/23 and 12/26/23, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. e. Transfer assessments, dated 12/29/23 and 1/8/24, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. f. Transfer summaries, dated 12/29/23 and 1/824, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents. 2. Patient #6 had a start of care date of 12/22/23 and a discharge date of 1/19/24. Clinical record review revealed the following: a. The Plan of Care, dated 12/22/23 to 2/19/24, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. b. Start of Care comprehensive assessment, dated 12/22/23, included an electronic signature with discipline name, but electronic signature lacked discipline credentials. c. Skilled nursing visit notes, dated 12/29/23, 1/5/24 and 1/10/24, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. d. Discharge assessment, dated 1/19/24, included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on agency policy review, clinical record review, patient interview, and agency staff interview, the agency failed to ensure accurate and thorough completion of pertinent components of the initial comprehensive assessment for 1 of 2 sampled patients with wound care. (Patient #1) Failure to accurately and thoroughly complete the comprehensive assessment to address individualized pertinent areas of health to obtain baseline findings placed patients at an increased risk of unidentified condition. Findings include: According to agency policy, titled Initial Assessments/Comprehensive Assessments, dated April 2023, each patient admitted will receive a comprehensive assessment. The comprehensive assessment will reflect the patient’s current health status. 1. Patient #1 had a start of care date of 12/19/23. Clinical record review revealed the following: a. The comprehensive assessment, dated 12/19/23, contained documentation the integumentary system was within normal limits, and indicated no pressure ulcers. b. The skilled nurses visit note dated, 12/27/23, contained documentation the integumentary system was assessed with no documented skin issues or pressure ulcers. c. Two missed visits were recorded with physician notification, documented for the dates of 1/3/24, and 1/10/24. d. During a home observation visit, 2/6/24 at 9:30 AM, surveyor observed Staff C, Registered Nurse, (RN) providing wound care to the right buttock. e. During the home visit the patient reported they had sustained a fall outside prior to their December admission to home care, and reported they had to wait for help to get up off the ground for some time. Patient reported it was sore at the time, but that they had not noted any drainage or opening to the area. Patient reported in January the area became very painful and the patient was taken to the local emergency room and was transferred to the University of Iowa Hospital where the wound had to be surgically debrided and received antibiotics. f. Hospital records from the University of Iowa, dated 1/11/24, revealed that patient was brought into Washington County Hospital on 1/10/24, transferred to the University of Iowa hospital on 1/11/24. Admission diagnosis was an infected right buttock pressure ulcer with necrotizing fasciitis. (flesh eating disease) Hospital records indicated that patient had a fever of 101.4 Fahrenheit with mental confusion also documented. Patient required surgery to remove the infected tissue in the wound. Agency failed to identify a wound during the initial comprehensive assessment. The above stated findings were reviewed with the agency Administrator and the Clinical Manager. The agency presented no additional information prior to the end of the survey.”

“Within 48 hours of the patient’s return CFR(s): 484.55(d)(2) Within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician or allowed practitioner - ordered resumption date; This Element is not met as evidenced by: Based on agency policy review and clinical record review, the agency failed to ensure completion of the update to the comprehensive assessment within 48 hours of the agency’s knowledge of return home from an inpatient facility for 1 of 3 sampled patients requiring a resumption of care assessment (Patient #4). The agency performed 29 resumption of care assessments in the previous 6 months. Failure to complete resumption of care comprehensive assessment in a timely manner increased the potential that patients might not receive services in a manner to meet individualized patient needs. Findings include: According to the agency policy, titled Reassessments/Update of the Comprehensive Assessment, the comprehensive assessment for resumption of care must be completed within 48 hours after the patient’s return home from a hospital admission of 24 hours or more for any reason other than diagnostic tests, or on physician/practitioner ordered resumption of care date. Patient #4 had a start of care date of 2/17/2020. Clinical record review revealed: a. The update to the comprehensive assessment at the time of resumption of care, dated 1/15/24, documented the patient had a physician ordered resumption of care date of 1/15/24 but lacked documentation of a date the agency was notified of the patient hospital discharge. b. Interim physician order, dated 1/15/24, included resumption of care orders that included the physician ordered resumption of care date as 1/15/24. c. The faxed paperwork from the hospital, dated 1/17/24, identified the patient admitted on 1/8/24 and discharged on 1/10/24. d. Home health aide visit note, dated 1/11/24, included documentation services were provided. Interview on 2/8/24 at 10:01 AM, the Administrator reported the registered nurse (RN) was scheduled to complete the resumption of care comprehensive assessment on 1/11/24 but was unable to complete the visit due to an ice storm. The home care aide was scheduled for a visit on 1/11/24 as well and was able to make it to the home prior to the ice storm. The nurse failed to obtain the physician ordered resumption of care date within 48 hours of the patient hospital discharge or to complete the update to the comprehensive assessment at the time of resumption of care within 48 hours of the patient hospital discharge. The update to the comprehensive assessment at the time of resumption of care was completed 5 days after the patient’s hospital discharge, and 3 days late as required by regulation and the agency’s own policy. The above stated findings were reviewed with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.”

“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 agency policy review, clinical record review, home visit observation and patient and staff interview, the agency failed to ensure the accurate completion of all components comprising the Plan of Care, including all supplies/equipment and medications used by the patient for 2 of 3 sampled patients with surveyor home observation visits (Patients #2 and #3). Failure to maintain complete and accurate Plans of Care with current orders placed the patients at risk to not receive services, medications and/or treatments according to assessed needs and physician orders. 2. Patient #3 had a start of care date of 9/23/20. Home visit observation, clinical record review, and accompanying patient interviews revealed the following: a. The Plan of Care, dated 1/6/24 through 3/5/24, included physician orders for skilled nursing services and medications: Spiriva Inhaler and Carboxymethylcellulose eye drops. b. The Medication Profile, dated 1/12/24, included medications: Spiriva Inhaler and Carboxymethylcellulose eye drops. c. During a home observation visit on 2/6/24, at 1:30PM, with Staff D, Licensed Practical Nurse (LPN), surveyor identified patient had medications on the medication profile that the patient no longer self-administered including a Spiriva Inhaler, and Carboxymethylcellulose eye drops. During an interview with Patient #3 during the home observation visit, Patient #3 reported they had not self-administered the two medications in a long time. Agency failed to identify and obtain orders to discontinue mediations patient no longer was self-administering including a Spiriva inhaler and Carboxymethylcellulose eye drops. The above findings were reviewed with the agency Administrator and the Clinical Manager. The agency presented no additional information prior to the end of the survey. Findings include: According to agency policy, titled Plan of Care – CMS #485 and Physician/Practitioners Orders, dated April 2023, the individualized plan of care must include all medications, supplies and equipment required. 1. Patient #2 had a start of care date of 12/24/2020. Clinical record review, home observation visit and accompanying interviews revealed the following: a. The Plan of Care, dated 12/9/23 to 2/6/23, identified tape, diabetic supplies, syringe, tub/shower bench, needles, walker, kerlix rolls, sharps container, alcohol pads, cpap (continuous positive airway pressure) machine, pill minder; and orders for medications. b. During a home visit observation on 2/6/24 at 12:05 PM, with Staff E, Registered Nurse (RN), Staff E set up medications in the pill minder and used a pill cutter to cut tablets in half prior to placing in the pill minder. Staff E questioned if the patient had checked their weight this morning. Staff E reported to the surveyor the patient received a scale and monitoring system from the VA (Veterans Administration), the patient checks their weight daily and the information is reported electronically to the VA. During the home visit observation on 2/6/24 at 12:05 PM, the patient reported using the scale and monitor daily to check weight. c .During an interview on 2/7/24 at 3:20 PM, the Clinical Manager reported agency practice is to list medication planners (pill minder), pill cutters, and scale and monitor as medical equipment used by the patient on the plan of care. This information may be listed under the DME (Durable Medical Equipment) and supplies section of the plan of care or in the narrative note. d. During the home visit observation on 2/6/24 at 12:05 PM, Staff E, RN, set up medications, including Tylenol 3 times a day and potassium daily. Staff E left a phone message for the VA case manager regarding the patient needing a refill on the lidocaine patches. Staff E reported these medications were long-term medications for patient, they had been on these for multiple years, unsure of exact start date. Staff E checked medication profile in electronic medical record and reported the medications were not on the current medication profile. The Plan of Care failed to identify the pill cutter, scale and monitor as medical equipment used by the patient and the Tylenol, potassium and lidocaine patches, medications used by the patient.”

“All orders recorded in plan of care CFR(s): 484.60(a)(3) All patient care orders, including verbal orders, must be recorded in the plan of care. This Element is not met as evidenced by: Based on agency policy review, clinical record review, and staff interview, the agency failed to maintain a working Plan of Care for patients and update the working Plans of Care with any new verbal/interim physician orders for 4 of 4 sampled patients with new verbal/interim orders. (Patients #1, #2, #4 and #7) Failure to update the Plan of Care increased the potential for medication errors in administration or inaccurate provision of care. 4. Patient #1 had a start of care of 12/19/23. Review of the clinical record revealed the following: a. The Plan of Care, dated 12/19/23 to 2/16/24, included orders for skilled nursing services, aide services, and medications for the patient. b. Resumption of care orders, dated 1/16/24 included physicians’ orders for change in skilled nursing frequency effective 1/22/24; skilled nurse to assess skin for breakdown every visit; and wound care orders to pack wound with Dakins soaked kerlix gauze, place in abdominal pad over wound and gauze, secure with tape, perform twice daily. The agency failed to ensure the POC was updated to include all patient care orders, including the resumption of care orders. The above stated findings were reviewed with the Administrator and the Clinical Manager. The agency presented no additional information prior to the end of the survey. Findings include: According to agency policy, titled Plan of Care – CMS #485 and Physician/Practitioners Orders, dated April 2023, all patient care orders, including verbal orders, must be recorded in the plan of care. The plan will be revised to reflect any verbal order received during the 60-day certification period so all agency staff are working from a current plan. During an interview on 2/6/24 at 11:43 AM, the clinical manager reported the agency enters interim physician orders in the computer when taken and the plan of care is updated at every recertification period. 1. Patient #2 had a start of care date of 12/24/2020. Clinical record review revealed the following: a. The Plan of Care, dated 12/9/23 to 2/6/24, included physician orders for skilled nursing services one time a week. b. Interim physician order, dated 1/19/24, for an extra skilled nursing visit. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 2. Patient #2 had a start of care date of 2/17/2020. Clinical record review revealed the following: a. The Plan of Care, dated 11/28/23 to 1/26/24, included diagnosis E10.43 Type 1 diabetes with diabetic autonomic (poly)neuropathy and physician orders for skilled nursing services 1 time every other week, home care aide services 1 time every week. b. Interim physician order, dated 1/4/24, to resume home care services; add new diagnoses E10.10 Type 1 diabetes mellitus with ketoacidosis without coma and J18.9 pneumonia, unspecified organism; and increase skilled nursing services to 1 time a week and home care aide services to 2 times a week. c. Interim physician order, dated 1/15/24, to resume home care services and start levofloxacin 750 mg capsule, 1 capsule daily for 7 days. The agency failed to ensure the Plan of Care was updated to include all patient care orders. 3. Patient #7 had a start of care date of 11/9/2020 and a discharge date of 12/22/23. Clinical record review revealed the following: a. The Plan of Care, dated 8/26/23 to 10/24/23, included physician orders for skilled nursing services and medications. b. Interim physician order, dated 10/23/23, to resume home care services and start new medications Nitrofurantin and Ciprofloxacin. The agency failed to ensure the Plan of Care was updated to include all patient care orders.”

“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 clinical record review, agency policy review and agency staff interview, the agency failed to ensure a registered nurse or other appropriate health care professional completed home health aide supervision at least every 14 days for 1 of 2 sampled patients who received hands on personal care services in conjunction with a skilled service provision (Patient #4). Failure to supervise home health aide services, at least every 14 days increased the risk that patients received unsatisfactory or inappropriate care from home health aides. Findings include: According to the agency’s policy, titled Home Health Aide Supervision, dated April 2023, a registered nurse must make an onsite visit to the patient’s home no less frequently than every 14 days. Patient #4 had a start of care date of 2/17/2020. Clinical record review revealed: a. Plan of Care, dated 11/28/23 to 1/26/23, included physician orders for skilled nursing and home health aide services. b. A skilled nursing visit note, dated 12/11/23, included documentation of home health aide supervision. c. A skilled nursing visit note, dated 12/26/23, included documentation of home health aide supervision (exceeding aide supervision requirements by 1 day). The nurse failed to complete home health aide supervision every 14 days as required by agency policy. During an interview on 2/8/24 at 10:01 AM, the Administrator reported no other clinical findings to present to the surveyors. The surveyor reviewed the above stated findings with the Administrator and Clinical Manager. The agency provided no additional information prior to the end of the survey.”

“Required items in clinical record CFR(s): 484.110(a)(1) The patient’s current comprehensive assessment, including all of the assessments from the most recent home health admission, clinical notes, plans of care, and physician or allowed practitioner orders; This Element is not met as evidenced by: Based on agency policy review, clinical record review and staff interview, the agency failed to ensure the clinical record included the patient’s Patient Service Agreement form for 3 of 3 sampled patients admitted in 2022 or later (Patients #3, #5 and #6). Failure of the agency to ensure the clinical record included all required documentation placed agency patients at risk to receive care or not receive care meeting the needs of the patient. 3. Patient #1 had a start of care date of 12/19/23. Clinical record review revealed the following: a. The initial comprehensive assessment, dated 12/19/23, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. b. A skilled nursing visit note, dated 12/27/24, was marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. c. Missed visit notification notes for the dates of 1/3/24, and 1/10/224 were marked as completed and included an electronic signature with discipline name, but the electronic signature lacked discipline credentials. Agency staff failed to appropriately authenticate the clinical record documents. The surveyor reviewed the above findings with the Administrator and Clinical Manager. No additional information provided prior to the end of the survey. Findings include: According to the agency policy, titled Medical Record Content, dated April 2023, the clinical record will contain evidence of consent for care on admission. During an interview on 2/7/24 at 11:58 AM, the Administrator reported the Patient Service Agreement form is completed on paper and scanned into the EMR, there is no paper chart. 1.Patient #6 had a start of care date of 12/22/23 and a discharge date of 1/19/24. Clinical record review revealed the following: a. Plan of Care, dated 12/22/23 to 2/19/24, included physician orders for skilled nursing services. b. Patient Service Agreement form was not identified in the electronic medical record (EMR). During an interview on 2/7/24 at 11:58 AM, the Administrator reported they were unable to locate the completed admission consent forms in the EMR. They contacted the admitting nurse who reported having the document but had been unable to scan into the EMR. On 2/7/24 at 2:34 PM, the Patient Service Agreement form was scanned and uploaded into the EMR. The agency failed to include the Patient Service Agreement in the clinical record as required by agency policy. 2.Patient #5 had a start of care date of 3/2/23. Clinical record review revealed the following: a. Plan of Care, dated 3/2/23 to 4/29/23, included physician orders for skilled nursing services. b. Patient Service Agreement form was not identified in the EMR. During an interview on 2/7/24 at 11:58 AM, the Administrator reported they were unable to locate the completed admission consent forms in the EMR. During an interview on 2/7/24 at 1:52 AM, Administrator reported the admitting nurse thought the patient had a signed copy in the home. On 2/7/24 at 3:34 PM, the Patient Service Agreement form was scanned and uploaded into the EMR. The agency failed to include the Patient Service Agreement in the clinical record as required by agency policy.”