International Health Solutions

“Preparing clinical notes CFR(s): 484.75(b)(6) Preparing clinical notes; This Element is not met as evidenced by: Based on record review, policy review and interview, the agency failed to ensure that clinical notes were completed timely for 5 patients (#6, #7, #10, #1 and #8), out of a total sample of 10 patients. Findings include: 4. For Patient #1, the Agency failed to ensure that clinical notes were signed after providing home visits. Patient #1 was admitted to the agency in March 2025 with diagnosis of Fibromyalgia (a long-term condition that involves widespread body pain and tiredness). Review of the physician’s order for certification period of 3/8/25-5/6/25, indicated orders for skilled nursing services one to two times a week. Review of the clinical record indicated that 11 of 13 skilled nursing visits notes were not signed and/or within 72 hours as required, including the following: *Visit note for 3/18/25 was completed and signed on 4/23/25. *Visit note for 3/20/25 was completed and signed on 4/23/25. *Visit note for 3/27/25 was completed and signed on 4/23/25. *Visit note for 3/31/25 was completed and signed on 4/23/25. *Visit note for 4/8/25 was completed and signed on 4/23/25. *Visit note for 4/10/25 was completed and signed on 4/23/25. *Visit note for 4/15/25 was completed and signed on 4/23/25. *Visit note on 4/17/25 was completed and signed on 4/23/25. *Visit note on 4/22/25 was completed and signed on 4/29/25. *Visit note on 4/23/25 was completed and signed on 4/29/25. *Visit note on 5/6/25 was completed and signed on 5/12/25. 5. For Patient #8, the Agency failed to ensure that clinical notes were signed after providing home visits. Patient #8 was admitted to the agency in November 2025 with diagnosis of encounter for aftercare following surgery on the digestive system. Review of the physician’s order for certification period of 11/14/24-1/11/25, indicated orders for skilled nursing services two to three times a week. Review of the clinical record indicated that 13 of 26 skilled nursing visits notes were not signed and/or within 72 hours as required, including the following: *Visit note for 11/22/24 was completed and signed on 11/29/24. *Visit note for 12/2/24 was completed and signed on 12/9/24. *Visit note for 12/4/24 was completed and signed on 12/9/24. *Visit note for 12/9/24 was completed and signed on 12/28/24. *Visit note for 12/11/24 was completed and signed on 12/28/24. *Visit note for 12/16/24 was completed and signed on 12/28/24. *Visit note for 12/18/24 was completed and signed on 12/28/24. *Visit note on 12/20/24 was completed and signed on 12/28/24. *Visit note on 12/23/24 was completed and signed on 12/28/24. *Visit note on 12/25/24 was completed and signed on 2/9/25. *Visit note on 12/30/24 was completed and signed on 1/9/25. *Visit note on 1/2/25 was completed and signed on 1/9/25. *Visit note on 1/4/25 was completed and signed on 1/9/25. During an interview on 5/14/25 at 12:45 P.M., the Clinical Manager said staff are required to complete and upload their visit documentation in the electronic medical record within 72 hours. She reviewed Patients #1 and #8 clinical records and said that the visit notes were all completed late. Review of the agency’s policy entitled, Clinical Record Contents and Maintenance, undated, indicated the following: *All documentation done by the clinicians in the clinical record in legible and accurate. *Hard-copy clinical visit notes and other associated documentation are completed the day of the patient visit and incorporated into the patient record within 72 hours. 1. For Patient #6, the agency failed to ensure the nurses completed and incorporated the visit documentation into the patient record within 72 hours per policy. Patient #6 was admitted to the agency in December 2022 with a diagnosis of Type 2 Diabetes Mellitus (chronic condition of high blood sugar related to insulin resistance). Review of the clinical record indicated that during the certification period of 3/28/25 through 5/26/25, the patient was to receive 1 skilled nursing visit a day. Further review of the clinical record indicated that for 2 of 46 visits, the documentation for the visits was not completed and incorporated into the patient’s record within 72 hours, as required, including the following: *The visit note for 3/29/25 was completed and signed 4/16/25. *The visit note for 3/30/25 was completed and signed on 4/16/25. 2. For Patient #7, the agency failed to ensure the nurses completed and incorporated the visit documentation into the patient record within 72 hours per policy. Patient #7 was admitted to the agency in April 2025 with a diagnosis of encounter for surgical care following surgery on the circulatory system. Review of the clinical record indicated that during the certification period of 4/23/25 through 6/21/25, the patient was to receive 1 to 2 skilled nursing visits a week. Further review of the clinical record indicated that for 2 of 5 visits, the documentation for the visits was not completed and incorporated into the patient’s record within 72 hours, as required, including the following: *The visit note for 5/5/25 was completed and signed 5/13/25. *The visit note for 5/9/25 was completed and signed on 5/13/25. 3. For Patient #10, the agency failed to ensure the nurses completed and incorporated the visit documentation into the patient record within 72 hours per policy. Patient #10 was admitted to the agency in February 2025 with a diagnosis of encounter for surgical care following surgery on the circulatory system. Review of the clinical record indicated that during the certification period of 2/13/25 through 4/13/25, the patient was to receive 1 to 2 skilled nursing visits a week. Further review of the clinical record indicated that for 7 of 15 visits, the documentation for the visits was not completed and incorporated into the patient’s record within 72 hours, as required, including the following: *The visit notes for 2/17/25, 2/21/25, 2/25/25, and 2/27/25 were all completed and signed 3/6/25. *The visit notes for 3/13/25, 3/24/25, and 3/26/25 were all completed and signed on 4/3/25. During an interview on 5/14/25 at 12:45 P.M., the Clinical Manager said staff are required to complete and upload their visit documentation in the electronic medical record within 72 hours. After reviewing the clinical documentation noted above for each of the 3 patients, she said they were all completed late. She said staff had not followed the policy as required.”