Apollo Medical

“Infection Prevention CFR(s): 484.70(a) Standard: Infection Prevention. The HHA must follow accepted standards of practice, including the use of standard precautions, to prevent the transmission of infections and communicable diseases. This Standard is not met as evidenced by: Based on policy review, observation, and interview the home health provider failed to ensure staff followed the provider’s policy when staff failed to clean their computer before placing it back into their bag in 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 provider’s undated policy titled, “Bag Technique,” showed in part that computers/tablets should be stored in an outside pocket but should be cleaned prior to placement in the pocket. RECORD/PATIENT #2: Observation on 01/23/2024, beginning at 2:35 PM, during the patient’s home visit, showed staff failed to clean their computer before placing it inside their bag. During an interview on 01/24/2024, beginning at 11:30 AM, the home health administrator stated that staff should clean their computers before placing them in their bag.”

“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, and interview, the home health provider failed ensure the timeliness of documentation in five of five full records reviewed (Records/Patients #1, #2, #3, #4, and #5). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #2: Review of the record showed: - An SN visit dated 11/28/23, and signed as completed on 12/02/2023 (four days after the visit); - An SN visit dated 12/26/2023, and signed as completed on 01/01/2024 (six days after the visit); and - An SN visit dated 12/27/2023, and signed as completed on 01/01/2024 (five days after the visit. RECORD/PATIENT #5: - An SN visit dated 11/16/2023 and signed as completed on 11/20/2023 (four days after the visit); and - An SN visit dated 11/21/2023 and signed as completed on 12/03/2023 (12 days after the visit). Findings included: Review of the provider’s undated policy titled,” Initial Assessment,” showed a complete comprehensive assessment will be completed in a timely manner, consistent with the patient’s immediate needs, but no longer than 5 calendar days after the start of care (SOC). Review of the provider’s undated policy titled,” Clinical Documentation Policy,” showed all documentation, regardless of visit type, must be submitted within 48 hours of a performed visit. RECORD/PATIENT #1: Review of the clinical record showed the following: -A skilled nurse (SN) visit dated 01/16/2024 documented 01/21/2024, 5 days after visit; -A physical therapy (PT) evaluation dated 01/09/2024 documented 01/17/2024, 8 days after visit; -An occupational therapy (OT) evaluation dated 12/26/2023 documented 01/02/2024, 7 days after visit; and -An OT visit dated 01/08/2024 documented 01/15/2024, 7 days after visit. RECORD/PATIENT #3: Review of the clinical record showed the following: -A SN initial assessment dated 12/20/2023 documented 12/28/2023, 8 days after visit; -A SN visit dated 12/27/2023 documented 12/31/2023, 4 days after visit; -An OT visit dated 01/03/2024 documented 01/15/2024, 12 days after visit; and -An OT missed visit dated 01/18/2024 documented 01/22/2024, 4 days after missed visit. RECORD/PATIENT #4: Review of the clinical record showed the following: -A certified occupational therapy assistant (COTA) visit dated 01/11/2024 documented 01/14/2024, 3 days after visit; and -A COTA visit dated 01/18/2024 documented 01/22/2024, 4 days after visit. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect documentation to be completed according to policy and within a timely manner.”

“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 the home health provider’s admission packet review and interview, the provider failed to ensure that the correct hours of operation of the state toll free home health hotline (7:00 AM to 8:00 PM, seven days a week) were provided to the patient in one of one admission packet reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the patient admission packet showed that the patient had the right to “be advised of the state toll free home health telephone hotline, its contact information, its hours of operation, and its purpose is to receive complaints or questions about local home health agencies (HHA). 1-800-392-0210; 7:00 AM - 12 midnight 7 days a week.” During an interview on 01/24/2024 at 3:30 PM, the home health administrator stated that he/she was not aware of the hour change from 7:00 AM - 12 midnight to 7:00 AM - 8:00 PM. He/she also stated that he/she would expect the correct hotline hours to be contained in the admission packets and provided to patients.”

“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, observation, and interview, the home health provider failed to identify all the medications a patient was taking in, but not limited to, two of five 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 undated policy titled, “Medication Reviews/Reconciliations,” showed, in part, the following: -Medication reconciliation is to consist of a reconciliation between discharge/patient medication lists (prescription and over the counter) found in the patient’s home and electronic medical record medication list, and -Medication reconciliation is done to ensure all patients are correctly and safely taking all medications. RECORD/PATIENT #1: Review of the document titled, “Medication Profile,” dated 01/23/2024 showed the patient was taking Warfarin (an oral anticoagulant commonly used to treat and prevent blood clots) 5 milligrams (mg) oral tablet, take one tablet by mouth once daily Monday-Friday. Take one tablet and one 1 mg tablet once daily Saturday and Sunday for a total of 6 mg. Observation on 01/23/2024 at 1:00 PM, during the patient’s home visit, showed a hand written updated medication list that stated the patient was taking Warfarin 5 mg every Monday, Tuesday, Wednesday, Friday, and Saturday. Take 4 mg every Thursday and Sunday. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect medications to match from the electronic medical record (EMR) to the home written list. RECORD/PATIENT #3: Review of the document titled, “Medication Profile,” dated 01/23/2024 showed the patient was taking the following medications: -Digoxin (used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat) 125 micrograms (mcg) oral tablet, take one tablet orally once daily; -Melatonin (used for improving sleep in different conditions) 3 mg oral tablet, take one tablet by mouth once daily at bedtime as needed; -Miralax oral powder (used to treat constipation) 17 grams, take by mouth once daily as needed; and -Senosol (used to treat constipation) 8.6 mg oral tablet, take one tablet two times a day as needed. During an interview on 01/23/2024 at approximately 5:00 PM, the patient’s caregiver stated that the patient was no longer taking these medications. Observation on 01/23/2024 at 5:00 PM, during the patient’s home visit, showed the patient was taking the following medications: -Trazodone (used to treat major depressive disorder) 50 mg tablet, take one tablet by mouth once daily at night; -Lexapro (used to treat major depressive disorder) 10 mg tablet, take one tablet by mouth once daily; -Metoprolol (used to treat high blood pressure) 25 mg extended release tablet, take one tablet by mouth once daily; -Albuterol (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases) 2.5 mg/3 milliliters (mL) nebulizer treatment, take 2.5 mg four times daily as needed; -Aspirin (can treat mild to moderate pain, inflammation or arthritis) 81 mg tablet, take one tablet once daily; -Vitamin D3 125 mcg/5000 mg, take one tablet once daily; -Move Free joint health dietary supplement (sodium 10mg, proprietary cartilage blend 40mg, boron 5mg, hyaluronic acid 3.3mg) take one tablet once daily; and -Acetaminophen 500 mg tablets, take two tablets three times daily. The provider’s medication profile failed to contain these medications. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect the medications to be reconciled at the initial visit as well as with any medication changes..”

“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 policy review, record review, and interview, the home health provider failed to ensure that the individualized plan of care (POC) contained all types of services, supplies, and equipment required for patient care in two of five full records reviewed (Records/Patients #2 and #4). This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Plan of Care,” showed, in part, the following: -A POC is the written orders for the individualized care for a patient; and -POC will be address at all Outcome and Assessment Information Set (OASIS) timepoints for accurate goals and interventions for the individual patient. RECORD/PATIENT #4: Review of the document titled, “Occupational Therapy (OT) Start of Care (SOC) OASIS,” showed the following: -Patient has “fallen 12 times over the past few months”; *The POC failed to contain interventions for fall risk; -Patient incontinent of bowel and bladder; *The POC failed to contain interventions for incontinence; -The patient used durable medical equipment (DME) such as transfer devices; and *The POC failed to contain interventions for DME. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect individualized interventions to be included on the POC. Findings included: Review of the provider’s undated policy titled, “Plan of Care,” showed in part: - A POC is the written orders for the individualized care for a patient; - All POCs will be updated to reflect any new or changed physician’s orders to assure correct treatment according to the POC; - Coordination of care between all disciplines and ordering physician will be documented; and - POC will be address at all Outcome and Assessment Information Set (OASIS) timepoints for accurate goals and interventions for the individual patient. Review of the initial assessment dated 11/22/2023, showed in part: -The patient had been hospitalized for two months after cardiothoracic bypass surgery. After extubation (removal of a tube that had been placed in the lungs to help with breathing) the patient was coughing while eating. The patient had lost 20 pounds while hospitalized. The patient has a good appetite and is trying to eat a soft high protein diet. The nurse encouraged the patient to drink ensure and cough after small bites; - Referrals were made to ST (speech therapy) and OT (occupational therapy); and -The nurse changed the abdominal dressing where the LVAD (heart assistive device) tubing was. The nurse noticed scant sanguineous (bloody) drainage. The patient stated that the drainage had decreased. Review of the POC dated 11/22/2023, showed the patient would benefit from skilled therapy. The POC failed to include orders for ST, OT, or abdominal dressing changes. During an interview on 01/24/2024, beginning at 11:30 AM, the administrator stated that the nurse should have called the physician to get orders. They should have notified the clinical manager and discussed therapy in case conference. The patient was probably not stable enough for physical therapy at that time, but there should be more information regarding therapy documented in their notes. There should have been orders for the abdominal dressing.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on record review and interview the home health provider failed to ensure physician orders were obtained for treatment in one of five full records reviewed (Record/Patient #2). This deficient practice has the potential to affect all patients served by the provider. Findings included: RECORD/PATIENT #2: Review of the initial assessment dated 11/22/2023, showed the nurse changed the abdominal dressing where the LVAD (heart assistive device) tubing was. The nurse noticed scant sanguineous (bloody) drainage. The patient stated that the drainage had decreased. Review of the skilled nurse (SN) visits showed on 12/12/2023, 12/19/2023, 12/20/2023, and12/26/2023 an intervention to assess surgical incision for healing and signs and symptoms of infection. Incision site-LVAD cord insertion site. Incision care-Cleanse with wound cleanser and cover with gauze. Review of the clinical record failed to show a physician order for this treatment. During an interview on 01/24/2023, beginning at 11:30 AM, the home health administrator stated that there should have been an order for the abdominal dressing.”

“Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient’s condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This Element is not met as evidenced by: Based on record review and interview the home health provider failed to ensure nursing staff notified the physician of one patient’s change in condition (Record/Patient #2) and failed to notify the physician of missed visits in one of five full records reviewed (Record/Patient #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the clinical record showed: -An occupational therapy (OT) visit scheduled for 01/12/2024 that was missed; -Two physical therapy (PT) visits scheduled for the week of 01/15/2024 that were missed; and -Two OT visits scheduled for the week on 01/15/2024 that were missed. The provider could not provide documentation to show that the physician was notified of the missed clinician visits. During an interview of 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect all missed visits to be reported to the physician or rescheduled. Findings included: RECORD/PATIENT #2: Review of the initial assessment dated 11/22/2023, showed the patient was admitted after a two month hospital stay. The patient had cardiothoracic bypass surgery. The patient had an LVAD (heart assistive device) placed while hospitalized. He/she also had a central line in the right upper chest and dobutamine (a medication that helps the heart pump blood) infusing. Review of the plan of care (POC) dated 11/22/2023, showed diagnoses that included atherosclerotic heart disease (damage or disease to the heart’s major blood vessels), end stage heart failure and presence of a heart assist device (a pump that helps the heart to pump blood to the body). Review of the skilled nurse (SN) visits showed: - On 12/27/2023, breath sounds were clear with no cough; - On 01/03/2024, the patient stated that he/she had been dealing with some health issues lately, including a nosebleed, diarrhea, and phlegm. Under the gastrointestinal assessment the patient had diarrhea and started Immodium (anti-diarrheal) one day ago. The LVAD (heart assistive device) nurse was aware. The patient had a productive cough with a small amount of clear and yellow thick sputum (phlegm). The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds, or that he/she notified the physician of the nosebleed, diarrhea, and productive cough with clear, yellow sputum; and - On 01/06/2024, the patient had a productive cough with a small amount of clear and yellow thick sputum. The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds, vital signs, or that he/she notified the physician of the patient’s productive cough with thick clear, yellow sputum. Review of the transfer OASIS (outcome assessment and information set) dated 01/08/2024, showed the patient was transferred to the hospital. Diagnoses included pneumonia, protein calorie malnutrition, left ventricular assist device present, and anemia. During an interview on 01/24/2024, beginning at 11:30 AM, the administrator stated that he/she would have expected the nurse to notify the physician of the patient’s nosebleed and productive cough. During an interview on 01/25/2024, beginning at 10:00 AM, the administrator stated that they did not have a specific policy regarding physician notification. They followed the conditions of participation for physician notification.”

“Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, observation, and interview the home health provider failed to ensure the patient received a visit schedule that included what disciplines were seeing the patient and the frequency of visits in 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 provider’s undated policy titled, “Plan of Care,” showed in part that written instructions will be provided to the patient/caregiver/patient representative. The written instructions will include the visit frequency for each discipline. RECORD/PATIENT #2: Observation and interview on 01/23/2024, beginning at 2:35 PM, during the patient’s home visit, showed the patient’s admission folder contained a blank form/calendar for visit schedules. The physical therapist stated that their schedule changed all the time, but they usually put the visit frequency on the form. During an interview on 01/24/2024, beginning at 11:30 AM, the home health administrator stated that staff should use the calendar for their visit schedules.”

“Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This Element is not met as evidenced by: Based on policy review, observation, and interview the home health provider failed to ensure the patient received a medication list in 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 provider’s undated policy titled, “Plan of Care,” showed in part that written instructions will be provided to the patient/caregiver/patient representative. The written instructions will include a medication list. RECORD/PATIENT #2: Observation and interview on 01/23/2024, beginning at 2:35 PM, showed the patient’s admission folder failed to contain a medication list for the patient. The patient stated that he/she did not think he/she had one. The only medication list he/she had was from the last time he/she was in the hospital. During an interview on 01/24/2024, beginning at 11:30 AM, the home health administrator stated that staff should use whatever medication list was in the home. Staff could use the discharge medication list and update that as needed.”

“Interdisciplinary assessment of the patient CFR(s): 484.75(b)(1) Ongoing interdisciplinary assessment of the patient; This Element is not met as evidenced by: Based on policy review, record review, and interview the home health provider failed to ensure nursing staff documented complete physical assessments to include vital signs and lung sounds for one patient (Record/Patient #2) and failed to document complete wound and pain assessments for one patient (Record/Patient #5) of five full records reviewed. This deficient practice has the potential to affect all patients served by the provider. Findings included: Review of the provider’s undated policy titled, “Wound Care,” showed in part: - A wound assessment to be completed at each visit to include tissue type, wound bed, wound exudate (drainage), periwound (surrounding skin) condition, pain level with dressing change, and size (length, width, and depth); and - Measurements are to be completed with the first visit of each week. During an interview on 01/25/2024, at 10:00 AM, the home health administrator stated that they did not have a specific policy for pain assessments. They were working on one, but it had not yet been approved. RECORD/PATIENT #2: Review of the record showed the patient was admitted on 11/22/2023, after a two month hospital stay. The patient had cardiothoracic bypass surgery. The patient had an LVAD (a heart assistive device that helps the heart to pump blood to the body). Review of the plan of care (POC) dated 11/22/2023, showed diagnoses that included atherosclerotic heart disease (damage or disease to the heart’s major blood vessels) and hypertensive heart disease with heart failure (a chronic disease that makes it harder for your heart to pump blood which can lead to heart failure). Review of the skilled nurse (SN) visits showed: - On 12/27/2023, breath sounds were clear with no cough; - On 01/03/2024, productive cough with a small amount of clear and yellow thick sputum (phlegm). The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds; and - On 01/06/2024, productive cough with a small amount of clear and yellow thick sputum. The respiratory findings showed no problems noted or verbalized. The nurse failed to document breath sounds or vital signs. During an interview on 01/24/2024, at 12:35 PM, the home health administrator stated that vital signs and breath sounds should be documented. RECORD/PATIENT #5: Review of the record showed the patient was admitted on 11/16/2023, after hospitalization for a colostomy takedown (a colostomy is a surgical procedure to create a passage from the large intestine to the outside of the body, a colostomy takedown is the reversal of the colostomy to reattach the colon to the rectum). Review of the POC dated 11/16/2023, showed an order for wound vac (vacuum assisted closure of a wound) dressing change two times a week, assess for signs and symptoms of wound infection, and assess for pain including pain level, frequency, location, quality, precipitating factors, and side effects. Review of the SN visits showed: - On 11/16/2023, the patient had daily, intermittent pain, relief measures included non-narcotic over the counter pain relievers, occasionally affected sleep, and day to day activities. The pain assessment failed to include the location, quality, precipitating factors, and effectiveness of pain relief measures. The nurse changed the wound vac dressing but failed to document an assessment/measurements of the wounds; - On 11/21/2023, the nurse failed to document measurements of the wounds; - On 11/24/2023, the nurse documented the anterior (front) medial abdomen midline surgical incision wound bed was clean. The nurse failed to document the tissue color of the wound bed, or whether drainage or odor was present. The nurse also failed to document measurements of the wounds. The patient had constant pain. Pain relief measures included non-narcotic over the counter pain relievers. The nurse failed to document the pain level, location, quality, precipitating factors, and effectiveness of pain relief measures; - On 11/28/2023, the patient had a physician appointment; - On 11/30/2023, the patient saw the surgeon and he/she applied steri strips to the anterior medial abdominal incision. The patient had moderate pain at a level of five (pain is rated on a scale of 0 to 10 with zero meaning no pain and 10 meaning the worst pain) daily intermittent pain that was aching and interfered with activity and movement. The patient used narcotic and over the counter pain relievers and was comfortable with his/her current treatment. The nurse failed to document the location of pain; - On 12/04/2023, the nurse failed to document a pain assessment; - On 12/07/2023, the patient saw his/her primary care physician and surgeon that day. The patient had increased abdominal pain the last few days. The pain assessment showed the patient had daily, intermittent, acute, aching pain at a level of two. The patient used narcotic and over the counter pain relievers. The patient was comfortable with his/her current treatment. The nurse failed to document the location of the pain. The family member said the wound vac was being discontinued. Steri strips (adhesive strips that protect and hold a wound together) were placed on the midline abdominal incision and the physician placed a wet to dry dressing on the old stoma site. A CT (computerized tomography, shows detailed images inside the body) scan was ordered for the following day. No abdominal redness, warmth, or swelling noted. The nurse would follow up with the physician for current wound care orders. The RNCM (registered nurse case manager) and home health office was notified; and - On 12/09/2023, the patient’s family notified the provider that the patient had passed away. During an interview on 01/24/2024, beginning at 2:55 PM, the home health administrator stated that the nurse should assess the wound bed, drainage, odor and measure the wounds weekly. He/she would expect a pain assessment to include the rating, location, and what made it better or worse.”

“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 record review, observation, and interview the home health provider failed to ensure staff followed the physician ordered plan of care (POC) in two of five full records reviewed (Records/Patients #2 and #3). This deficient practice has the potential to affect all patients served by the provider. RECORD/PATIENT #3: Review of the verbal orders dated 01/11/2024 showed the following occupational therapy (OT) orders: -Activities of daily living (ADL) training; -Aerobic capacity training; -Assess ADL skills; -Assess aerobic capacity; -Assess transfer ability; -Establish/upgrade home exercise program/walking program for aerobic capacity/activity tolerance; and -Instruct patient/caregiver on safety awareness, energy conservation, compensation techniques for safe performance of ADLs, proper use of adaptive/assistive devices. Observation on 01/23/2024 at 5:00 PM, during the patient’s home visit, showed OT-A failed to perform the ordered interventions for the patient’s care. During an interview on 01/25/2024 at 9:00 AM, the home health administrator stated that he/she would expect care to be performed as ordered by the physician. Findings included: RECORD/PATIENT #2: Review of the record showed the patient was admitted on 11/22/2023, after a two month hospital stay. The patient had cardiothoracic bypass surgery. The patient had an LVAD (heart assistive device) placed while hospitalized. He/she also had a central line in the right upper chest and dobutamine (a medication that helps the heart pump blood) infusing. Review of the POC dated 11/22/2023, showed an order for central line/PICC (peripherally inserted central catheter) line care weekly. The nurse was to measure the upper arm circumference and distance from the IV (intravenous) hub to the insertion site at the start of care, discharge, and as needed for IV complications. Review of the initial assessment dated 11/22/2023, showed the nurse failed to document measurements of the upper arm circumference and length of the central line catheter. Review of the nursing visit dated 11/28/2023, showed the nurse failed to document that he/she changed the central line/PICC line dressing. During an interview on 01/24/2024, beginning at 11:30 AM, the administrator stated that they should have the catheter measurements on the referral, but sometimes it was difficult to obtain those measurements. Staff should document these measurements and document they changed the central/ PICC line dressing.”