Centerwell Home Health

“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 record review and interview the agency failed to ensure that a registered nurse conducted an initial assessment visit to determine the immediate care and support needs of the patient within 48 hours of referral, or on the physician ordered start of care date for 3 of 7 patient records reviewed. (Patient #3, #5, & #6) This failure could have resulted in a delay in addressing patients’ needs and required services in a timely manner and could cause a decline in patients’ health status. Findings included: Patient #3: Record review of a Patient Coordination Note Report for Patient #3 dated 01/27/25 indicated intake/referral from Hospital G. Record review of a Patient Coordination Note Report for Patient #3 dated 01/29/25 indicated verbal order SOC information was 01/29/25. Further review indicated date/time verbal order was received 01/29/25 at 12:00 p.m. Discipline ordered was SN for diagnosis type 2 diabetes (body either doesn’t produce enough insulin, or it resists insulin) with associated peripheral neuropathy (causes pain, numbness, tingling, and weakness in the hands and feet from nerve damage). Record review of Patient #3’s POC dated 01/30/25 to 03/30/25 indicated a SOC date of 01/30/25, and indicated she was 67 years old with diagnoses including diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), depression (loss of pleasure or interest in activities for long periods of time), and dependence on wheelchair. The POC indicated Patient #3 was ordered skilled nursing visits 1 time a week for 9 weeks. Record review of a Patient Calendar Report for Patient #3 dated 01/30/25 to 03/26/25 indicated an RN Oasis Admission visit date was on 01/30/25 (3 days after referral received and 1 day after ordered SOC date). Patient #5: Record review of a Patient Coordination Note Report for Patient #5 dated 11/15/24 indicated intake/referral from Hospital H. Record review of a Patient Coordination Note Report for Patient #5 dated 11/15/24 by the Administrator indicated call placed to Dr. F office regarding orders for home health, office closed. The note indicated agency would call again on Monday 11/18/24. Record review of a Patient Coordination Note Report for Patient #5 dated 11/18/24 indicated verbal order SOC information was 11/18/24. Further review indicated date/time verbal order was received 11/18/24 at 9:00 a.m. Disciplines ordered were SN for diagnosis right hip pain, compression fracture of L1 (a fracture of the first lumbar vertebra (L1) in the lower back), and PT to evaluate and treat to assist with strengthening and endurance. Record review of Patient #5’s POC dated 11/19/24 to 01/07/25 indicated a SOC date of 11/19/24, and indicated he was 88 years old with diagnoses including fracture of first lumbar vertebra (a serious injury that can cause severe pain and affect posture), hemiplegia (a condition that causes paralysis or weakness on one side of the body) following cerebral infarction (blood flow to the brain is interrupted, causing brain tissue to die), pressure ulcer of sacral region (wound or sore that develops on the skin over the sacrum bone (located near the tailbone) due to prolonged pressure on that area), pressure ulcer of right heel unstageable (type of pressure injury where the true depth of the wound cannot be determined because it is covered by a thick layer of dead tissue), Parkinson’s ( chronic brain disorder that causes movement problems, including tremors, stiffness, and balance issues), atrial fibrillation (irregular heart beat), diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), depression (loss of pleasure or interest in activities for long periods of time), and long term use of anticoagulants (blood thinners). The POC indicated Patient #3 was ordered skilled nursing visits 1 time a week for 9 weeks, physical therapy 1 time a week for 1 week, and home health aide 1 time a week for 1 week then 2 times a week for 8 weeks. Record review of a Patient Calendar Report for Patient #5 dated 11/19/24 to 01/16/25 indicated an RN Oasis Admission visit date was on 11/19/24 (4 days after referral received and 1 day after ordered SOC date). Patient #6: Record review of a Patient Coordination Note Report for Patient #6 dated 09/03/24 indicated intake/referral from Hospital J. Record review of a Patient Coordination Note Report for Patient #6 dated 09/04/24 by the Administrator indicated patient discharging from hospital 09/04/24. Patient to establish care with new PCP on Monday 09/09/24. Record review of a Patient Coordination Note Report for Patient #6 dated 09/12/24 indicated verbal order SOC information was 09/12/24. Further review indicated date/time verbal order was received 09/12/24 at 11:30 a.m. Discipline ordered was SN for diagnosis of Congestive Heart Failure (heart can’t pump blood well enough to meet your body’s needs). Record review of Patient #6’s POC dated 09/13/24 to 11/11/24 indicated a SOC date of 09/13/24, and indicated she was 79 years old with diagnoses including hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), chronic obstructive pulmonary disease (lung diseases that cause airflow obstruction and breathing problems), atrial fibrillation (irregular heart beat), low back pain, long term use of anticoagulants (blood thinners), dependence on supplemental oxygen (treatment that provides extra oxygen to breathe in), and history of falls. The POC indicated Patient #6 was ordered skilled nursing visits 1 time a week for 1 week, then 2 times a week for 2 weeks, then 1 time a week for 6 weeks. Record review of a Patient Calendar Report for Patient #6 dated 09/13/24 to 11/07/24 indicated an RN Oasis Admission visit date was on 09/13/24 (10 days after referral received and 1 day after ordered SOC date). During an interview on 02/18/25 at 3:19 p.m., the RN Administrator/Supervising Nurse said the agency saw patients after referral within 24-28 hours. She said if the agency could not see the patient until after 48 hours the agency reached out to the Dr. and got a new order date. She said it was documented in coordination notes. During an interview on 02/21/25 at 10:18 a.m., RN C said for admissions the office scheduled the visits and she called patients to set up a time to go see them. She said for an admit, VA had a specific date otherwise unless the Dr. specified a date, it was done within 48 hours. She said she was not sure if the agency had to get a new order from the doctor if it was not done within the timeframe. During an interview on 02/21/25 at 11:51 a.m., RN E said she and RN C did admissions within 24 hours after they got Dr. order, then the agency had 48 hours to get everything in. She said if the RN could not make it within 48 hours it was usually due to patient or family request and the RN would call the office and Dr. She said it would be the next day the RN would go see the patient after the order. During an interview on 02/21/25 at 3:40 p.m., the RN Administrator/Supervising Nurse said initial and comprehensive assessments were done by RNs and PTs and the timeframe was 48 hours. She said if it was not done within 48 hours, they had to get clarification from the Dr. She said the 48 hours was from when the agency received the verbal order from the physician that could admit the patient. She said if there was an order with a referral then the agency would admit within 48 hours. During an interview on 02/21/25 at 3:42 p.m., the RN Administration/Supervising Nurse said the agency ensured initial assessments were conducted within the required timeframe by looking at the intake coordination note and reviewing the codes in the note. During an interview on 02/21/25 at 3:50 p.m., the RN Administrator/Supervising Nurse said initial assessments were done within 48 hours of Dr. order. She said if it was not done the patient was at risk of rehospitalization. During an interview on 02/21/25 at 4:01 p.m., the RN Administrator/Supervising Nurse said the start of care was done within 48 hours after the Dr. order due to the agency had to have an order for home health and could not admit a patient without orders. She said she thought they were doing it right. Record review of a Patient Assessments policy dated 08/2024 indicated “…Initial assessment visit: the Home Health agency will conduct an initial assessment visit to the patient within 48 hours of the referral for services OR within 48 hours of the patients discharge from an inpatient facility OR on the date the physician/allowed practitioner specifies care is to start. If the Home Health agency receives a referral and cannot make the first visit within 48 hours of the referral or patient discharge from an inpatient facility, the Home Health agency will contact the respective physician/allowed practitioner or referring entity with knowledge of the patient’s current condition. Approval will be obtained for a specific start of care date or referral to another home health agency provider for services…””

“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 observation, record review and interview, the agency failed to ensure the comprehensive assessment accurately reflected the patient’s status which included all active health and medical problems for 1 of 7 patient records reviewed. (Patient #3) Patient #3’s comprehensive assessment did not include type or location of the dialysis access site. This failure prevented the agency from developing a plan of care that would address all active health and medical concerns for Patient #3. Findings included: Record review of Patient #3’s POC dated 01/30/25 to 03/30/25 indicated a SOC date of 01/30/25, and indicated she was 67 years old with diagnoses including diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), depression (loss of pleasure or interest in activities for long periods of time), and dependence on wheelchair. The POC indicated Patient #3 was ordered skilled nursing visits 1 time a week for 9 weeks. The POC indicated SN to observe/assess/monitor AV fistula (incorrect) (a surgically created connection between an artery and a vein in the arm, which allows for easy access to a large blood flow needed to perform hemodialysis) for any signs and symptoms of infection every SN visit. Record review of a Physician’s Order for Patient #3 dated 02/19/25 (after surveyor entrance) indicated upon chart review, it was noted on initial 485(POC) that the intervention was incorrect: SN to observe/assess/monitor AV fistula for any signs and symptoms of infection every SN visit. Dialysis center to monitor on dialysis days. The order indicated intervention should read SN to observe/assess/monitor central venous catheter (thin, flexible tube inserted into a large vein near the heart to provide access for hemodialysis) for any signs and symptoms of infection every SN visit. Dialysis center to monitor on dialysis days. Record review of a RN Oasis Admission Visit Note Report/assessment for Patient #3 dated 01/30/25 by RN C indicated care management special treatments, procedures, and programs: check all of the following treatments, procedures, and programs that apply on admission included dialysis. Further review indicated type of dialysis on admission was hemodialysis. Further review of the narrative section indicated patient to receive skilled nursing for assessment… monitoring of dialysis port site. The visit note report did not include the type, location, or assessment of the dialysis access site. During a home visit observation on 02/21/25 at 9:00 a.m., surveyor observed Patient #3 had a dialysis access site/catheter to her right chest with a dressing in place. During an interview on 02/21/25 at 9:27 a.m., Patient #3’s family member said patient only had a chest port. She said Patient #3 had been on dialysis since August (2024). During an interview on 02/21/25 at 10:18 a.m., RN C said the OASIS was completed by the RN who completed the admit. She said a patient with a chest catheter for dialysis the SN monitored for signs and symptoms of infection and dialysis monitored it on dialysis days. She said the access location should be on the OASIS and to monitor the site. During an interview on 02/21/25 at 11:51 a.m., RN E said the RN completed the OASIS, asked questions, got medications, diagnosis, and paperwork, then entered it and sent it to the coder. She said the dialysis site, location, and how many lumens (tubes) were on the OASIS. RN E said if a patient had a port or “outlet” that was part of the assessment. She said the assessment of the site was in the note at the end of the visit and under skin assessment. She said location of the site and documentation was in the narrative. She said the SN documented on the location whether there were problems or not each SN visit. RN E said the timeframe for visit documentation was by 9:00 a.m. the following morning. She said case managers and the RN Administrator reviewed notes and charts routinely. During an interview on 02/21/25 at 12:28 p.m., RN C said assessments included assessing the bandage each SN visit to ensure it was clean, dry, and intact. She said the assessments of the site should be documented in the narrative. She said she did not remember if she documented on the dialysis site when she first saw Patient #3. She said the agency “liked” for visit notes to be turned in by midnight the same night/day of visit. She said a dialysis site assessment should be documented on with or without issues. She said “some” nurses might document it under skin if it was not in the narrative. During an interview on 02/21/25 at 3:37 p.m., the RN Administrator/Supervising Nurse said the timeframe for clinicians to turn in documentation following a visit was within 24 hours. She said the SN were told they had to turn in visits by the following morning at 9:00 a.m. She said a report was ran weekly and reviewed and it let the agency know how many visits were not turned in. During an interview on 02/21/25 at 3:44 p.m., the RN Administrator/Supervising Nurse said the SN was supposed to assess ports every visit. She said assessments were documented under the skin assessment or in the narrative. She said a reason for it not being documented was if they (SN) didn’t see any signs and symptoms of infection, but it should be. She said the SNs were more likely to chart if something was abnormal and would notify the physician. She said there was no reason why the SN would not assess. The RN Administrator/Supervising Nurse said by not assessing/documenting it could cause risk for infection and the SN not being aware. She said she audited visit notes but did not audit them all. She said she audited all hospitalization records or if something was going on with the patient. During an interview on 02/21/25 at 3:47 p.m., the RN Administrator/Supervising Nurse said she on initial/OASIS she did not think in the electronic medical system there was a place to put in the assessment (of the site) and the SN would have to put it in the narrative or somewhere they could “free text”. She said the SN should put the assessment in the narrative on the initial assessment and when they assessed the site. Record review of a Signed Job Description by RN C and dated 10/19/20 for the RN position indicated “…Implement, develop, document and evaluate the Plan of Care (POC) to ensure quality and continuity of care. Obtain data on physical, psychological, social, spiritual and cultural factors that may influence patient/family health status and incorporate that data in to the Plan of Care (POC). Assure continuity of quality patient care delivered with appropriate documentation. Maintain up-to-date patient records so that all visits, contacts, problems, plans, actions and goals are accurately and clearly stated and changes are reflected as they occur…” Record review of a Medical Record Documentation policy dated 10/2022 indicated “…All documentation, including any documentation created using the “Copy-and-Paste Function”, must adequately and accurately document the following in a sufficient manner to comply with usual clinical practice standards, billing rules, state/federal/regulatory requirements and all other applicable Company clinical documentation policies… clinical encounter… assessment…General requirements… The medical record user’s signature will serve as their attestation that the entered information is accurate and that all information is current and accurately represents the Clinical Associate’s own provided services or assessment for that date of service…” Record review of a Patient Assessments policy dated 08/2024 indicated “…OASIS Data Collection: The Home Health agency will collect OASIS data response items and other pertinent information for each agency patient receiving skilled care to be billed to Medicare/Medicaid (primary or secondary) and those patients under a managed-care or Medicaid waiver program according to Company procedures… Clinical Associates who participate in collaborative efforts in OASIS data collection must function within the scope of their practice and state licensure and document collected data in the patient’s medical record…””

“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 observation, interview and record review, the agency failed to ensure the POC contained the required elements to cover all patient specific interventions and education for 1 of 7 patient records reviewed for plans of care. (Patient #3) Patient #3’s POC did not include the correct type or location of the dialysis access site (needle or catheter is inserted to allow for the removal and return of blood during dialysis treatment), or the days Patient #3 went to dialysis treatments to assure coordination of care. This failure could result in Patient #3 not receiving proper care/instruction to the dialysis access site and could lead to complications/hospitalization and could cause lack of coordination of care or missed visits. Findings included: Record review of Patient #3’s POC dated 01/30/25 to 03/30/25 indicated a SOC date of 01/30/25, and indicated she was 67 years old with diagnoses including diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), depression (loss of pleasure or interest in activities for long periods of time), and dependence on wheelchair. The POC indicated Patient #3 was ordered skilled nursing visits 1 time a week for 9 weeks. The POC did not indicate the correct type of dialysis access site, or location of the access site or the days Patient #3 went to dialysis treatments to assure coordination of care. The POC indicated SN to observe/assess/monitor AV fistula (incorrect) (a surgically created connection between an artery and a vein in the arm, which allows for easy access to a large blood flow needed to perform hemodialysis) for any signs and symptoms of infection every SN visit. Record review of a Physician’s Order for Patient #3 dated 02/19/25 (after surveyor entrance) indicated upon chart review, it was noted on initial 485(POC) that the intervention was incorrect: SN to observe/assess/monitor AV fistula for any signs and symptoms of infection every SN visit. Dialysis center to monitor on dialysis days. The order indicated intervention should read SN to observe/assess/monitor central venous catheter (thin, flexible tube inserted into a large vein near the heart to provide access for hemodialysis) for any signs and symptoms of infection every SN visit. Dialysis center to monitor on dialysis days. Record review of Patient #3’s medical record did not indicate the location of the dialysis access site or the days she went to dialysis treatments. During a home visit observation on 02/21/25 at 9:00 a.m., surveyor observed Patient #3 had a dialysis access site/catheter to her right chest with a dressing in place. During an interview on 02/21/25 at 9:27 a.m., Patient #3’s family member said patient only had a chest port and never had a dialysis access in her arms. She said Patient #3 had been on dialysis since August (2024). During a home visit/interview on 02/21/25 at 9:28 a.m., Patient #3 requested SN visit on Tuesdays due to dialysis Mondays, Wednesdays, and Fridays at 11:00 a.m. During an interview on 02/21/25 at 10:18 a.m., RN C said a patient with a chest catheter for dialysis the SN monitored for signs and symptoms of infection and dialysis monitored it on dialysis days. RN C said the 485/POC was developed by the RN who did the OASIS. She said if a patient was on dialysis the POC should include to monitor fistula for infection, bruit(vibration), catheter monitor for infection, weights, or calf measurements. She said the location of the access site should be on the POC. She said she was not sure if the days patients went to dialysis was on the 485 and the SN put it in their narrative. RN C said the RN Administrator (also the Supervising Nurse) looked over all 485s/POCs. She said the 485 was updated with changes, at recertification, and at resumption of care. During an interview on 02/21/25 at 10:25 a.m., RN C said the POC for Patient #3 which indicated fistula was entered in error and it was corrected. During an interview 02/21/25 at 11:51 a.m., RN E said the 485/POC was created when the OASIS was finished then went to the office and the supervisor reviewed. She said when the RN did the OASIS it transferred to the 485/POC. She said the RN always included when the patient received dialysis treatments and the days patients went so the SN tried not to schedule visits on dialysis days. RN E said the location of the dialysis access site was listed on the 485. She said if these things were not on the 485 the nurse that followed could miss assessing the site and knowing that it (dialysis site) was there could get missed. During an interview on 02/21/25 at 1:03 p.m., LVN D said for dialysis patients the SN checked the port for signs and symptoms of infection. She said location site was on the 485/POC. She said Patient #3 used to go to dialysis Tuesdays, Thursdays, and Saturdays, but changed not long ago to Mondays, Wednesdays, and Fridays. During an interview on 02/21/25 at 3:41 p.m., the RN Administrator/Supervising Nurse said the POC was developed by the admitting clinician on SOC. She said for dialysis the POC should include signs and symptoms of infection on access site. She said the location of the site should be on the POC. The RN Administrator/Supervising Nurse said sometimes the SN did not put the days of dialysis on the 485/POC, normally they put 3 times a week because sometimes the days would change. She said Patient #3 recently changed days. During an interview on 02/21/25 at 3:47 p.m., the RN Administrator/Supervising Nurse said she audited all 485/POCs as soon as they come in, then “pushed” them to coding. She said everyday she was working on 485s. She said if a dialysis site was not on a 485/POC, for AV fistula the SN wouldn’t be able to do anything on that arm, and for a port/catheter, the SN wouldn’t know where to assess. Record review of a Signed Job Description by RN C and dated 10/19/20 for the RN position indicated “…Implement, develop, document and evaluate the Plan of Care (POC) to ensure quality and continuity of care. Obtain data on physical, psychological, social, spiritual and cultural factors that may influence patient/family health status and incorporate that data in to the Plan of Care (POC). Assure continuity of quality patient care delivered with appropriate documentation. Maintain up-to-date patient records so that all visits, contacts, problems, plans, actions and goals are accurately and clearly stated and changes are reflected as they occur…” Record review of a Care Planning policy dated 09/2024 indicated “…The individualized POC is developed for the patient 60-day episode of care and must include all pertinent patient-relevant diagnoses, types of services, supplies and equipment required, all medications and treatments, safety measures to protect patient from injury, patient-specific interventions… an integration of services, whether provided directly or under arrangement, to assure coordination of care provided by all disciplines… The POC serves to ensure effective utilization and management of services, resources, discipline-specific visits frequency and duration as needed to address a patient’s condition, skilled needs or unique situation in accordance with physician/allowed practitioner written orders...” Review of Central Venous Catheter information dated 07/28/22 and accessed at https://my.clevelandclinic.org/health/treatments/23927-central-venous-catheter on 02/25/25 indicated “A central venous catheter (CVC) is a long, flexible tube your provider inserts into a vein in your neck, chest, arm or groin. It leads to your vena cava, a large vein that empties into your heart… When should I see my healthcare provider? Call your provider immediately if you have signs or symptoms of a CVC infection. These include: Fever, pain or tenderness near your port or hub, redness or red streaks in the surrounding skin, warm or swollen skin, yellow or green drainage, also call your provider right away if your catheter looks like it’s getting longer. This may signal that it’s coming out of your vein…””

“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 observation, record review and interview, the agency failed to maintain clinical records to ensure that care and services were completely and accurately documented for 1 of 7 patients whose clinical record was reviewed. (Patient #3) Patient #3’s record did not include location of the dialysis access site or assessments of the site. This failure could result in infection or complications of Patient #3’s dialysis access site and could lead to hospitalization. Findings included: Record review of Patient #3’s POC dated 01/30/25 to 03/30/25 indicated a SOC date of 01/30/25, and indicated she was 67 years old with diagnoses including diabetes mellitus (body either doesn’t produce enough insulin, or it resists insulin), hypertensive heart disease with heart failure (heart can’t pump blood well enough to meet your body’s needs), end stage renal disease (kidneys are no longer able to work at a level needed for day-to-day life), dependence on renal dialysis (a treatment to clean your blood when your kidneys are not able to), depression (loss of pleasure or interest in activities for long periods of time), and dependence on wheelchair. The POC indicated Patient #3 was ordered skilled nursing visits 1 time a week for 9 weeks. The POC indicated SN to observe/assess/monitor AV fistula (incorrect) (a surgically created connection between an artery and a vein in the arm, which allows for easy access to a large blood flow needed to perform hemodialysis) for any signs and symptoms of infection every SN visit. Record review of a Physician’s Order for Patient #3 dated 02/19/25 (after surveyor entrance) indicated upon chart review, it was noted on initial 485(POC) that the intervention was incorrect: SN to observe/assess/monitor AV fistula for any signs and symptoms of infection every SN visit. Dialysis center to monitor on dialysis days. The order indicated intervention should read SN to observe/assess/monitor central venous catheter (thin, flexible tube inserted into a large vein near the heart to provide access for hemodialysis) for any signs and symptoms of infection every SN visit. Dialysis center to monitor on dialysis days. Record review of a RN Oasis Admission Visit Note Report/assessment for Patient #3 dated 01/30/25 by RN C indicated care management special treatments, procedures, and programs: check all of the following treatments, procedures, and programs that apply on admission included dialysis. Further review indicated type of dialysis on admission was hemodialysis. Further review of the narrative section indicated patient to receive skilled nursing for assessment… monitoring of dialysis port site. The visit note report did not include the type, location, or assessment of the dialysis access site. Record review of a SN Visit Note Report/assessment for Patient #3 dated 02/05/25 by LVN D indicated patient normally did not take blood pressure prescription(medication) on dialysis day. The visit note report did not include the type, location, or assessment of the dialysis access site. Record review of a SN Visit Note Report/assessment for Patient #3 dated 02/11/25 by LVN D gave no indication patient was on dialysis as the note did not mention anything regarding dialysis. The visit note report did not include the type, location, or assessment of the dialysis access site. Record review of Patient #3’s medical record did not indicate the location of the dialysis access site or assessments of the site. During a home visit observation on 02/21/25 at 9:00 a.m., surveyor observed Patient #3 had a dialysis access site/catheter to her right chest with a dressing in place. During an interview on 02/21/25 at 9:27 a.m., Patient #3’s family member said patient only had a chest port. She said Patient #3 had been on dialysis since August (2024). During a home visit/interview on 02/21/25 at 9:28 a.m., Patient #3 requested SN visit on Tuesdays due to dialysis Mondays, Wednesdays, and Fridays at 11:00 a.m. During an interview on 02/21/25 at 10:18 a.m., RN C said the OASIS was completed by the RN who completed the admit. She said a patient with a chest catheter for dialysis the SN monitored for signs and symptoms of infection and dialysis monitored it on dialysis days. She said the access location should be on the OASIS and to monitor the site. During an interview on 02/21/25 at 11:51 a.m., RN E said the RN completed the OASIS, asked questions, got medications, diagnosis, and paperwork, then entered it and sent it to the coder. She said the dialysis site, location, and how many lumens (tubes) were on the OASIS. RN E said if a patient had a port or “outlet” that was part of the assessment. She said the assessment of the site was in the note at the end of the visit and under skin assessment. She said location of the site and documentation was in the narrative. She said the SN documented on the location whether there were problems or not each SN visit. RN E said the timeframe for visit documentation was by 9:00 a.m. the following morning. She said case managers and the RN Administrator reviewed notes and charts routinely. During an interview on 02/21/25 at 12:28 p.m., RN C said assessments included assessing the bandage each SN visit to ensure it was clean, dry, and intact. She said the assessments of the site should be documented in the narrative. She said she did not remember if she documented on the dialysis site when she first saw Patient #3. She said the agency “liked” for visit notes to be turned in by midnight the same night/day of visit. She said a dialysis site assessment should be documented on with or without issues. She said “some” nurses might document it under skin if it was not in the narrative. During an interview on 02/21/25 at 1:03 p.m., LVN D said for dialysis patients the SN checked the port for signs and symptoms of infection. She said location site was on the 485/POC. She said Patient #3 used to go to dialysis Tuesdays, Thursdays, and Saturdays, but changed not long ago to Mondays, Wednesdays, and Fridays. LVN D said the days of dialysis would be in the narrative part of the note on the SN visit. She said she thought she documented it, but she guessed she didn’t. LVN D said she usually “tried” to assess the site every time she went and if there were any signs and symptoms of infection, she would notify the RN and primary care. LVN D said sometimes she forgot to document the dialysis site assessment and she may have documented on 1 of them (visits). She said visit notes were due within 24 to 48 hours in the clinical note. She said the assessment of the dialysis site should be in the clinical note and by not documenting the assessment the SN would not know how the port was and if it showed any signs and symptoms of infection. LVN D said she did assess Patient #3’s dialysis site “last time” and sometimes Patient #3 showed it (site) to her. She said she did not know if she assessed the site the previous visit because the patient had frequent urinary tract infections so sometimes, she went straight to the UTI issues. During an interview on 02/21/25 at 3:37 p.m., the RN Administrator/Supervising Nurse said the timeframe for clinicians to turn in documentation following a visit was within 24 hours. She said the SN were told they had to turn in visits by the following morning at 9:00 a.m. She said a report was ran weekly and reviewed and it let the agency know how many visits were not turned in. During an interview on 02/21/25 at 3:44 p.m., the RN Administrator/Supervising Nurse said the SN was supposed to assess ports every visit. She said assessments were documented under the skin assessment or in the narrative. She said a reason for it not being documented was if they (SN) didn’t see any signs and symptoms of infection, but it should be. She said the SNs were more likely to chart if something was abnormal and would notify the physician. She said there was no reason why the SN would not assess. The RN Administrator/Supervising Nurse said by not assessing/documenting it could cause risk for infection and the SN not being aware. She said she audited visit notes but did not audit them all. She said she audited all hospitalization records or if something was going on with the patient. During an interview on 02/21/25 at 3:47 p.m., the RN Administrator/Supervising Nurse said she on initial/OASIS she did not think in the electronic medical system there was a place to put in the assessment (of the site) and the SN would have to put it in the narrative or somewhere they could “free text”. She said the SN should put the assessment in the narrative on the initial assessment and when they assessed the site. Record review of a Signed Job Description by RN C and dated 10/19/20 for the RN position indicated “…Implement, develop, document and evaluate the Plan of Care (POC) to ensure quality and continuity of care. Obtain data on physical, psychological, social, spiritual and cultural factors that may influence patient/family health status and incorporate that data in to the Plan of Care (POC). Assure continuity of quality patient care delivered with appropriate documentation. Maintain up-to-date patient records so that all visits, contacts, problems, plans, actions and goals are accurately and clearly stated and changes are reflected as they occur…” Record review of a Signed Job Description by LVN D and dated 09/03/24 for the LVN position indicated “…Understands own work area professional concepts/standards, regulations, strategies and operating standards. Makes decisions regarding own work approach/priorities, and follows direction. Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation…” Record review of a Medical Record Documentation policy dated 10/2022 indicated “…All documentation, including any documentation created using the “Copy-and-Paste Function”, must adequately and accurately document the following in a sufficient manner to comply with usual clinical practice standards, billing rules, state/federal/regulatory requirements and all other applicable Company clinical documentation policies… clinical encounter… assessment…General requirements… The medical record user’s signature will serve as their attestation that the entered information is accurate and that all information is current and accurately represents the Clinical Associate’s own provided services or assessment for that date of service…” Record review of a Patient Assessments policy dated 08/2024 indicated “Policy: Patient assessments will be performed by a qualified Clinical Associate who has demonstrated verbal/written knowledge of the specific skills needed to perform assessments including specialty assessments… Additional assessments will be completed as appropriate based on discipline-specific physician/allowed practitioner orders and patient needs… Each discipline will assess patients based on their respective scope of practice… Reassessments: The patient is assessed on an ongoing basis by qualifying disciplines to evaluate the appropriateness and effectiveness of the plan of care…””