Community Home Health and Restorative Care

“Plan of care CFR(s): 484.60(a)(1) Each patient must receive the home health services that are written in an individualized plan of care that identifies patient-specific measurable outcomes and goals, and which is established, periodically reviewed, and signed by a doctor of medicine, osteopathy, or podiatry acting within the scope of his or her state license, certification, or registration. If a physician or allowed practitioner refers a patient under a plan of care that cannot be completed until after an evaluation visit, the physician or allowed practitioner is consulted to approve additions or modifications to the original plan. This Standard is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure an individualized plan of care (POC) that included all patient-specific interventions, in three of five full records reviewed (Records/Patients #1, #2, and #4). This deficient practice has the potential to affect the coordination of care and services for all patients on service with the provider. Findings included: Review of the provider’s policy titled, “Plan of Care (POC),” dated 05/2020 showed, in part: - The plan of care is a written plan that specifies the care and services necessary to meet the patient-specific needs; and -The POC is developed in consultation with staff, patient, physician and other providers involved in the patient’s care; and - The POC includes all medications and treatments and patient-specific interventions and education. RECORD/PATIENT #1: Review of the clinical record, showed, in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of the referral record, dated 12/03/2024 showed, in part: - The patient had a past medical history that included the diagnosis of “type 2 diabetes mellitus without complications, with long-term current use of insulin” (a long-term condition in which the body has trouble controlling the levels of sugar in the blood); and - The patient to “check blood sugars 3 times weekly” (a type of blood test that checks the amount of sugar levels within the blood). Review of the POC dated 12/04/2024, failed to show orders/interventions for blood sugar checks three times a week. During an interview on 01/15/2025 that began at 10:45 AM, the Clinical Manager stated that: - The blood sugar check frequency of three times a week was on the referral; and - He/she has no idea how it was missed and left off of the POC. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care; and - The patient resided in an apartment with a friend. Review of the referral record, dated 01/02/2025 showed, in part: - The patient had a past medical history that included the diagnosis of type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling the levels of sugar in the blood) with foot ulcer and was on insulin (an injectable medication used to help regulate blood sugar). Review of the SOC (start of care) visit note, dated 01/03/2025, showed a glucose meter (a portable machine that measures the amount of sugar in a small blood sample) had been called into the pharmacy. Review of the POC dated 01/03/2025 to 03/032025 showed: - Insulin lispro 100 unit/ml (milliliter) sliding scale insulin (the dose is adjusted based on the blood sugar level before a meal) pen before meals subcutaneously (the fatty tissue just under the skin). For blood sugar 100-150 give 6 units, for blood sugar greater than 151 give 10 units; and - It failed to list a frequency for the blood sugar to be checked. RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 12/16/2024 with a primary diagnosis of malfunction of tracheostomy stoma (the failure to function in a normal manner of a surgically created opening in the neck that allows air to reach the lungs). Review of the referral record, with a service date of November 24, 2024, showed, in part: the tracheostomy is capped on room air. Review of the SOC (start of care) visit note, dated 12/16/2024, showed the trach is not used and is capped off. Review of the POC, dated 12/16/2024 to 02/13/2024, failed to show evidence the trach was capped off. During an interview on 01/15/2025 at 10:36 AM the administrator stated that it was kind of a grey area. It was in the SOC assessment that the trach was capped off so it probably should have been on the POC. During an interview on 01/12/2025 at 10:40 AM the clinical manager stated that ideally, he/she would expect that the trach being capped off was listed on the POC.”

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure all documented entries were complete, clear, and accurately reflected the skilled visit, in one of three home visit observations (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Assessments,” dated 05/2020, showed in part: - The POC (plan of care) includes all medications and treatments and patient-specific interventions and education; and - All patients will receive an assessment according to the Physician services ordered. Review of the provider’s policy titled, “Wound Care,” dated 05/2020, showed in part: - Assess patient for wound(s); - The wound shall be measured weekly and documented in the patient’s record to show a progression or decline; - All wound care education is to be documented in nursing notes; and - Education with the patient and/or caregiver regarding wound prevention and wound healing will be ongoing and documented in the patient’s record. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of a POC, dated 12/04/2024, showed in part: - SN (skilled nurse) visit frequency of 2 week 1 (two times a week for one week) and 1 week 8 (one time a week for eight weeks); - SN to assess and instruct on diabetic care to include: diet, activity, stress, foot care, and skin care; - SN to perform diabetic foot care including monitoring for the presence of skin lesions on lower extremities and patient/caregiver education on proper foot care; and - Observation and assessment of integumentary system. Review of the SN visit note, dated 01/14/2025 at 8:00 AM, during the survey home visit observation with RN A, showed: - Diabetic foot screen section showed, “not assessed during this visit” (RN A assessed both feet during the observation visit); - Skin assessment section showed, poor skin turgor (This section failed to include further documentation of the additional assessment findings, SN interventions and education that was provided during the observation visit); - The wound assessment section showed the wound care that was performed to the left elbow and the wound measurements that were obtained (The documentation failed to show the dressing changes that were performed on the bottom of the left foot and buttocks that were being used to maintain skin integrity and prevent skin breakdown); - The clinical notes visit summary section, showed in part: * SN contacted PCP (primary care provider) office and left a message in regards to a rash and bruised area to the patient’s left shoulder; * “SN educates about seeing the PCP in regards to bruised area and rash”; * “SN educates on dressing changes to prevent skin breakdown. Patient and (spouse) verbalize understanding”; * The “PCP office calls SN back reports to have the patient monitor area if it does not go away to make an appointment with PCP. PCP also reports that patient can have visitors so long as rashes are covered. Patient made aware of this”; and - The skilled nurse visit failed to include documentation that showed: * RN A referred to the patient’s rash as “shingles” (a viral infection that causes a painful rash) during the observation visit; * RN A assessed the patient’s skin and educated the patient and spouse that the shingles “looked better” since the previous visit but “a new area” was located on the patient’s lower back; * RN A educated the patient and spouse to avoid having visitors while the patient had shingles; * RN A informed the patient and the spouse that when he/she received a return call from the PCP office, he/she would ask the doctor if it was okay if family came to visit; * RN A removed the silicone foam dressings (used to maintain skin integrity) from the bottom of the left foot and buttocks so he/she could assess the areas and obtain photos; * RN A cleansed the areas of concern prior to applying skin prep and new foam dressings; and * The visit documentation failed to include coordination of care details with the urologist office, new foley catheter orders/interventions obtained at the beginning of the observation visit clarifying that the new orders could start after the supplies were received, and detailed interventions performed by RN A during the changing of the patient’s foley catheter. During an interview on 01/15/2025 that began at 10:45 AM, the administrator stated that he/she would expect the documentation to be complete and accurately reflect the visit.”

“HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator’s name, business address, and business phone number in order to receive complaints. This Element is not met as evidenced by: Based on policy review, review of the provider’s patient rights information in the home binder, home visit observation, and interview, the home health provider failed to provide, in writing the correct business address, in, but not limited to, one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Admission Documentation/Patient Education” (policy number C:4), dated initiated “05/2020”, showed in part: - “Named provider” will be in compliance with state and federal regulations regarding patient admission paperwork; - The patients of “named provider” will receive paperwork upon admission per state, local, and federal regulation; and - The following forms/documents shall be reviewed by our agency’s (provider’s) clinician upon the initial visit to the new patients or prior to initiating services: patient rights and responsibilities in writing. Review of the admission binder provided upon entrance to the provider on 01/13/2025, showed on the binder cover, on page 1 (one) and page 19, the address failed to be listed correctly. Each had the address listed as 100 East Main, Fairfax Missouri 64446. The current address is 208 East 5th Street Mound City, Missouri 64470. Review of a letter from “Named” Medicare billing service showed an approval for change of information (primary practice location address) dated 11/27/2024. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care. Observation on 01/12/2025 at 4:37 PM, during the patient’s home visit, when reviewing of the patient rights information in the admission binder showed if failed to have the correct/current Mound City address listed. (The previous Fairfax address was still listed). During an interview on 01/15/2025 at 10:03 AM, the administrator stated that he/she: - Had emailed “named person” (the program assistant of the Bureau of Home Care and Rehabilitative Standards) of the address change on 11/01/2024; - Realized it (the address) was incorrect in the admission binder and on the patient rights information, but it was fixed at that time; - The date on the 855 (Medicare enrollment form) of the address change was 11/01/2024; - They would send out a letter to all the current patients with the correct information; and - They had it fixed at that time.”

“State toll free HH telephone hotline CFR(s): 484.50(c)(9) Be advised of the state toll free home health telephone hot line, its contact information, its hours of operation, and that its purpose is to receive complaints or questions about local HHAs. This Element is not met as evidenced by: Based on policy review, review of the Missouri Adult Abuse and Neglect Hotline Online reporting system, review of the home health provider’s current patient rights information, home visit observation, and interview, the provider failed to provide written notice of the correct state toll free home health hotline number hours of operation in, but not limited to, one of three home visits observed (Patient/Record #2). This deficient practice has the potential to adversely affect the knowledge and comprehension of the rights and responsibilities of all the providers patients. Findings included: Review of the home health provider’s policy titled, “Admission Documentation/Patient Education” (policy number C:4), dated initiated “05/2020”, showed in part: - “Named provider” will be in compliance with state and federal regulations regarding patient admission paperwork; - The patients of “named provider” will receive paperwork upon admission per state, local, and federal regulation; - The following forms/documents shall be reviewed by our agency’s (provider’s) clinician upon the initial visit to the new patients or prior to initiating services: patient rights and responsibilities in writing; and - “State hotline numbers, office phone (accreditation body hotline after accreditation)”. Review of the Missouri Adult Abuse and Neglect Hotline Online Reporting System showed the hotline hours of operation as 7 (seven) AM to 8 (eight) PM, 365 days a year. Review of the patient rights listed in the admission binder provided upon entrance to the provider on 01/13/2025, showed on page 7 and page 10, the hotline hours failed to be listed correctly. They were incorrectly listed as “7 AM to Midnight 7 days a week”. RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care. Observation on 01/12/2025 at 4:37 PM, during the patient’s home visit, when reviewing of the patient rights information in the admission binder showed if failed to have the correct hotline hours. The hours were incorrectly listed as “7 AM to Midnight 7 days a week”. During an interview on 01/15/2025 at 10:03 AM, the administrator stated that: - He/she knew they had that fixed; - The COO (Chief Operating Officer that is responsible for printing the binders) needed to delete the old files out; - They would send out a letter to all current patients with the correct information; and - They had it fixed at that time.”

“Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This Element is not met as evidenced by: Based on policy review, review of the Quality Improvement Organization (QIO) website, review of the home health provider’s current patient rights information, home visit observation, and interview, the provider failed to update the written notice of patient rights to meet the requirements of the federal home health regulations to include the name address and phone number of the current QIO that serves the area where the patient resides in, but not limited to, one of three home visit observations (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the home health provider’s policy titled, “Admission Documentation/Patient Education” (policy number C:4), dated initiated “05/2020”, showed in part: - “Named provider” will be in compliance with state and federal regulations regarding patient admission paperwork; - The patients of “named provider” will receive paperwork upon admission per state, local, and federal regulation; and - The following forms/documents shall be reviewed by our agency’s (provider’s) clinician upon the initial visit to the new patients or prior to initiating services: patient rights and responsibilities in writing. Review of the QIO website for Missouri, showed the following: Livanta LLC P.O. Box 2687 Virginia Beach, VA 23450 (888)755-5580 TTY (teletypewriter) 711. Review of the admission binder, including the patient right’s information, provided upon entrance to the provider on 01/13/2025, showed on page 11, Livanta failed to be listed as the QIO. (No organization was listed, just an address of 5918 West Courtyard Drive, Austin, Texas 78730-5036 and a phone number of 800-725-9216). RECORD/PATIENT #2: Review of the clinical record showed the patient was admitted to home health services on 01/03/2025 with a primary diagnosis of a stage two pressure ulcer/injury (a partial thickness loss of the skin caused by unrelieved pressure) of the right medial foot with skilled nursing visits to provide wound care. Observation on 01/12/2025 at 4:37 PM, during the patient’s home visit, when reviewing of the patient rights information in the admission binder showed it failed to have the correct QIO listed. (No organization was listed, just an address of 5918 West Courtyard Drive, Austin, Texas 78730-5036 and a phone number of 800-725-9216). During an interview on 01/15/2025 at 10:03 AM, the administrator stated that he/she: - Was unaware the correct QIO was not listed; and - Would send out a letter to all the current patients with the correct information.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on policy review, clinical record review, and interview the home health provider failed to ensure the initial assessment was completed within 48 hours of the referral in one of five full records reviewed (Record/Patient #4). This deficient practice has the potential to affect the immediate care needs of all the provider’s patients. Findings included: Review of the providers policy titled “Assessments” (policy number C: 7), dated initiated 05/2020, showed in part: - All patients referred to our agency (provider) will receive an assessment according to the physician services ordered; and - An initial SOC (start of care) assessment will be performed by the primary care RN (registered nurse) unless therapy only case, then PT (physical therapy) or SLP (speech/language pathologist) within 48 hours of the patient’s referral, discharged from the facility to home or specific date specified by the MD (medical doctor). RECORD/PATIENT #4: Review of the clinical record showed the patient was admitted to home health services on 12/16/2024 with a primary diagnosis of malfunction of tracheostomy stoma (the failure to function in a normal manner of a surgically created opening in the neck that allows air to reach the lungs). Review of a faxed referral from the patient’s PCP (primary care provider), showed in part: - A handwritten date of 11/27/2024 on the faxed referral cover sheet; and - A time stamped date in the upper left-hand corner of the faxed referral cover sheet of 12/07/2024. Review of the SOC OASIS (Start of Care Outcome and Assessment Information Set; a standardized data collection tool) dated 12/16/2024, (Nineteen days from the handwritten referral date and nine days from the time stamped date on the referral) showed: - Item M0104- Date of referral 12/16/2024; Item M0102- Date of physician-ordered SOC (start of care) marked NA (non-applicable), no specific date ordered by physician. Further review of the clinical record showed the following undated documentation; - Referral 12/16/2024; - MD-ordered SOC: 12/16/2024; - Point of Origin: Clinic referral; - Notes: “Patient requested SOC date for 12/15/2024. PCP notified and updated referral date to 12/16/2024.”; and - There failed to be any documentation within 48 (forty-eight) hours of referral of any communication regarding the late start of care (the documentation was undated). During an interview on 01/15/2025 at 10:36 AM, the clinical manager stated that he/she had nothing to show the actual date the PCP was contacted about changing the SOC date per patient request.”

“Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient’s status, and must include, at a minimum, the following information: (1) The patient’s current health, psychosocial, functional, and cognitive status; This Element is not met as evidenced by: Based on policy review, record review, and interview, the home health provider failed to ensure the comprehensive assessment accurately reflected the patient’s current health status including relevant past medical history in, one of five full records reviewed (Record/Patient #1). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Assessments,” dated 05/2020, showed in part: - The comprehensive assessment must accurately reflect the patient’s status and must include, current health, psychosocial, functional and cognitive status; and - Systems assessment including, integumentary (skin) status. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of the referral record, dated 12/03/2024, showed in part: - The patient had a past medical history that included the diagnosis of “type 2 diabetes mellitus without complications, with long-term current use of insulin” (a long-term condition in which the body has trouble controlling the levels of sugar in the blood); - The patients “blood sugar levels have been stable, with no instances of hypoglycemia;” - The patient to “check blood sugars 3 (three) times weekly” (a type of blood test that checks the amount of sugar levels within the blood); and - The patient had an “approx. (approximately) 3mm (millimeter) superficial abrasion (a minor skin injury that occurs when the skin’s surface layers are broken) to left elbow.” Review of the SOC visit note dated 12/04/2024, showed in part: - The endocrine (a group of glands and organs that produce and release hormones into the bloodstream) status section showed that the patient was a diabetic, “controlled by insulin injection,” and “blood sugar: random,” (No documentation of blood sugar ranges); and - “The patient has areas of concern to buttock and left bottom foot;” - The SN (skilled nurse) educated the patient and the spouse on “skin care techniques” and provided the patient and the spouse with “supplies to prevent skin breakdown;” and - The documentation failed to include the status of the abrasion to the left elbow. During an interview on 01/15/2025 that began at 10:45 AM, the clinical manager stated that: - He/she would have expected the SN to assess the patient’s blood sugar ranges; - He/she was only able to find skin assessment documentation related to the areas of concern to the buttocks and the left bottom foot; and - He/she was unsure why the SN did not document the abrasion to the left elbow.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on policy review, record review, home visit observation and interview, the home health provider failed to ensure an accurate medication review and/or update of the patient medications was completed, in one of three home visit observations (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Assessments,” dated 05/2020 ,showed in part: - The comprehensive assessment must accurately reflect the patient’s status and must include, a review of all medications (current, including over the counter and supplements)/medication instruction; and - Every skilled visit will have a physical assessment and routine assessment of the patient’s home. RECORD/PATIENT #3: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/24/2024 with primary diagnosis of neurocognitive disorder with Lewy bodies (a type of progressive dementia caused by degeneration of the tissues in the brain, that leads to a decline in thinking, reasoning and independent function); and - The patient resided at home with his/her spouse. On 01/14/2025 at 2:10 PM, during the home visit observation with OT (occupational therapist), showed the following medication discrepancies: - Mannose cranberry 900mg/500mg (a supplement containing 900 milligrams of mannose and 500 milligrams of cranberry in each capsule) 1 (one) capsule daily was being administered (The provider’s medication profile failed to include this supplement). - Calcium citrate-vitamin D3 (supplement)/ 315MG (milligrams) calcium- 6.25mcg (micrograms) 1 tablet daily was being administered (The provider’s medication profile showed the frequency of every 48 hours); and - The patient’s spouse managed and administered the patient’s medications using his/her own handwritten medication list. During an interview on 01/15/2025 that began at 10:45 AM, the clinical manager stated that: - He/she was surprised that the spouse had his/her own handwritten medication list because the nurse (RN A) usually filled out a paper medication list on admission; - The medication profile was last updated with medication changes on 01/10/2025 during the last skilled nursing visit; and - He/she was not sure if the patient’s spouse didn’t inform the nurse about the medication changes or if the changes were made since the nurse had been there last.”

“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 policy review, record review, home visit observation, and interview, the home health provider failed to ensure that education and treatments were provided as ordered by the physician, in two of five full records reviewed (Records/Patients #1 and #3). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s policy titled, “Plan of Care (POC),” dated 05/2020, showed in part: - The plan of care is a written plan that specifies the care and services necessary to meet the patient-specific needs; - Individualized written plan of care which would specify the care and services necessary to meet the patient’s needs, including the patient and caregiver education and training specific to the patient’s care needs; - The POC includes all medications and treatments and patient-specific interventions and education; and - The POC will include any additional interventions/orders the provider/physician chose to include. Review of the provider’s policy titled, “Wound Care,” dated 05/2020, showed in part: - Wounds are not to be treated without doctor orders; - Continue dressing changes and supplies as prescribed by the physician; - Obtain new orders as needed from the physician for lack of healing and new wounds; and - Education with the patient and/or caregiver regarding wound prevention and wound healing will be ongoing and documented in the patient’s record. RECORD/PATIENT #1: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/04/2024 with a primary diagnosis of encounter for fitting and adjustment of urinary device (foley catheter- a flexible tube that drains urine from the bladder into a bag outside of the body) with a secondary diagnosis of malignant neoplasm (cancer) of prostate (a gland below the bladder and in front of the rectum in men that produces fluid for semen); and - The patient resided in the home with his/her spouse as the primary caregiver. Review of a physicians order, dated 12/26/2024, showed in part: - SN (skilled nurse) to perform/instruct on wound care; and - Wound care for skin tear to left elbow, cleanse with Vashe wash (a solution for cleansing, irrigating, moistening, and debriding acute and chronic wounds) or wound cleanser, apply Tegaderm absorbent (a sterile, transparent and waterproof wound dressing that helps protect wounds from bacteria and viruses), change weekly and PRN (as needed), and okay for caregiver to perform dressing changes. Observation on 01/14/2025 at 8:00 AM, with RN (registered nurse) A, showed: - RN A performed wound care to the patient’s left elbow; - After RN A cleansed the wound with wound cleanser, he/she sprayed the patient’s left elbow with skin-prep (a fast-drying, liquid film-forming skin protectant that prepares damaged or intact skin for the application of adhesive dressings) prior to applying the tegaderm absorbent dressing; and - The wound care orders failed to include the use of skin prep to the patient’s left elbow. During an interview on 01/15/2025 that began at 10:45 AM, the administrator stated that the use of skin prep needed to be included in the wound care orders. RECORD/PATIENT #3: Review of the clinical record, showed in part: - The patient was admitted to home health services on 12/24/2024 with primary diagnosis of neurocognitive disorder with Lewy bodies (a type of progressive dementia caused by degeneration of the tissues in the brain, that leads to a decline in thinking, reasoning and independent function); and - The patient resided at home with his/her spouse. Review of a SN visit note, dated 01/10/2025, showed that the SN provided education on the importance of TED hose (elastic stockings/socks that gently squeeze the legs to improve blood flow and circulation) and the patient agreed to put the TED hose back on after his/her shower. Review of the POC failed to include orders/interventions for TED hose. During an interview on 01/15/2025 that began at 10:45 AM, the clinical manager stated that: - The referral did show orders/interventions for TED hose; - The POC failed to include orders/interventions for TED hose; and - They (the staff) needed to be making sure that they had orders for them.”