Medi Home Health and Hospice

“Based on agency policy, clinical record review, and staff interviews, the Plan of Care did not include individualized interventions for 2 of 19 records [#3 and 7]. The findings included: The policy, Plan of Care [3/25], was provided by the agency administrator on 10/15/25 at 4:50 pm. The policy stated, “...The plan of care includes interventions, goals, and services tailored to the patient and family’s needs...”1. Patient # 3 had a Start of Care date of 8/30/25 with a terminal diagnosis of interstitial pulmonary disease [a group of chronic lung conditions that cause inflammation and scarring of the lung tissue]. Review of the Plan of Care [POC] for the certification period 8/30/25-11/27/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 13 weeks. Further review of the POC revealed the following intervention related to respiratory function “Tracheostomy [surgical procedure that creates an opening in the trachea (windpipe) to provide an airway and facilitate breathing]: Patient/caregiver demonstrate proper management and aseptic technique in trach care”. Review of the updated POC dated 9/4/25 revealed the same intervention. A review of the clinical record revealed the patient did not have a tracheostomy. During an interview with the agency administrator on 10/16/25 at approximately 10:30 am, the administrator confirmed the POC was not individualized for Patient # 3. 2. Patient # 7 had a Start of Care date of 8/10/25 with a terminal diagnosis of idiopathic pulmonary fibrosis [a progressive disease characterized by a progressive and irreversible decline in lung function]. Review of the Plan of Care [POC] for the certification period 8/10/25-11/7/25 included orders for SN [skilled nursing [3 times a week for 1 week, 2 times a week for 12 weeks. Further review of the POC revealed the following interventions related to shortness of breath -“Perform/assess/educate on proper trach [tracheostomy - [surgical procedure that creates an opening in the trachea (windpipe) to provide an airway and facilitate breathing] care and suctioning techniques” and “Provide/assess/educate on respiratory management devices, including pleural catheter [ thin, flexible tube inserted into the pleural space to drain excess fluid] care”. The patient did not have a tracheostomy or a pleural catheter. During an interview with the agency administrator on 10/16/25 at approximately 10:30 am, the administrator confirmed the POC was not individualized for Patient # 7.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to update the plan of care with planned visit frequencies for the next 15 days for 18 of 18 patients [#1, 2, 3, 4, 6, 7, 9, 11, 12, 15, 16, 18, 8, 10, 6, 13, 19] receiving MSW [medical social worker] visits; and failed to enter IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] notes for 11 of 18 [#1, 6, 7, 9, 11, 15, 16, 18, 10, 13, 19] patients with MSW services. The findings included: 13. Patient #8 had a Start of Care (SOC) date of 9/19/2025 and a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease (High blood pressure leading to kidney disease). The Plan of Care (POC) for the certification period of 9/19/2025 - 12/17/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 13 weeks; hospice aide 2 times a week for 13 weeks; Medical Social worker (MSW) 1 time a month for 4 months; Chaplain 1 time a month for 4 months. Review of the clinical record revealed that the IDG meeting conducted on 10/2/2025 had no MSW visit projections for the next 15 days. During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POC for MSW was not updated with visit projections for the next 15 days during the 10/2/2025 IDG meeting.14. Patient #10 had a Start of Care (SOC) date of 8/23/2025 and a terminal diagnosis of other symptoms and signs involving cognitive functions following cerebral infarction (cognitive impairment related to having a disruption of blood supply to a part of the brain causing tissue death). The Plan of Care (POC) for the certification period of 8/23/2025-11/20/2025 included orders for Skilled nursing (SN) 2 times a week for 13 weeks; hospice aide 2 times a week for 1 week, 1 time a week for 12 weeks; Medical Social worker (MSW) 1 time a month for 4 months; Chaplain 1 time a month for 4 months. Review of the clinical record revealed that IDG meetings were conducted on 9/4/2025, 9/19/2025, and 10/2/2025. Review of the 9/4/25 and 10/2/25 IDG meeting minutes revealed no visit projections for the next 15 days by the MSW. Review of the 9/19/25 IDG meeting minutes revealed no IDG note by the MSW. During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POCs for the MSW were not updated with visit projections for the next 15 days during the 9/4/2025 or 10/2/25 IDG meetings. The administrator also confirmed there was no IDG note entered by the MSW for the 9/19/25 meeting. 15. Patient #13 had a Start of Care (SOC) date of 8/9/2025 and a terminal diagnosis of Hemiplegia (paralysis or unable to move) and hemiparesis (weakness) affecting one side of the body. The Plan of Care (POC) for the certification period of 8/9/2025-10/13/2025 included orders for Skilled nursing (SN) 2 times a week for 3 weeks, 1 time a week for 6 weeks, 1 time a week for 9 weeks; Hospice aide 3 times a week for 8 weeks; Medical Social worker (MSW) 1 time a month for 2 months. Review of the clinical record revealed that IDG meetings were conducted on 8/21/2025, 9/4/2025, 9/19/2025, and 10/2/2025. Review of the 8/21/2025 and 9/19/2025 IDG meeting minutes revealed no visit projections for the next 15 days by the MSW. Review of the 9/4/2025 and 10/2/2025 IDG meeting minutes revealed no IDG note by the MSW. During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POCs for the MSW were not updated with visit projections for the next 15 days during the 8/21/2025 and 9/19/2025 IDG meetings. The administrator also confirmed there was no IDG note entered by the MSW for the 9/4/2025 and 10/2/2025 meetings.16. Patient #19 had a Start of Care (SOC) date of 7/18/2025 and a terminal diagnosis of senile degeneration of the brain (age related decline in memory, behavior, and cognitive ability). The Plan of Care (POC) for the certification period of 7/18/2025-10/15/2025 included orders for Skilled nursing (SN) 1 time a week for 12 weeks; hospice aide 1 time a week for 12 weeks; Medical Social worker (MSW) 1 time a month for 3 months; Chaplain 1 time a month for 3 months. Review of the clinical record revealed that IDG meetings were conducted on 7/24/2025, 8/7/2025, 8/21/2025, 9/4/2025, 9/19/2025, and 10/2/2025. Review of the 7/24/2025, 9/4/2025, and 9/19/2025 IDG meeting minutes revealed no visit projections for the next 15 days by the MSW. Review of the 8/7/2025, 8/21/2025, and 10/2/2025 IDG meeting minutes revealed no IDG note by the MSW.During an interview with the administrator on 10/16/2025 at approximately 10:10 am, the administrator confirmed the POCs for MSW were not updated with visit projections for the next 15 days during the 7/24/2025, 9/4/2025, and 9/19/2025 IDG meetings. The administrator also confirmed there was no IDG note entered by the MSW for the 8/7/2025, 8/21/2025, and 10/2/2025 meetings. The policy, Plan of Care [revised 3/25], was provided by the agency administrator on 10/15/25 at 4:50 pm. The policy stated, “...The plan of care will be reviewed, revised and documented in the patient’s clinical record by the interdisciplinary team at least every 15 days...”The policy, Interdisciplinary Group [revised 6/2025], was provided by the agency administrator on 10/14/25 at 2:03 pm. The policy stated, “...The IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] meets at least every 15 days to...review and revise plans of care...”1. Patient # 1 had a Start of Care date of 11/6/24 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body’s needs]. Review of the Plan of Care for the certification period 11/6/24-2/3/25 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 9 weeks; hospice aide 1 time a week for 9 weeks; MSW [medical social worker] 1 time a month for 3 months. Review of the IDG [interdisciplinary group- team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed IDG meetings were conducted on 11/14/24, 11/28/24, and 12/12/24. Further review of the minutes revealed no visit projections for the next 15 days from the MSW for the 11/14/24 or 12/12/24 meetings, and no narrative note from the MSW for the 11/28/24 IDG meeting.2. Patient # 2 had a Start of Care date of 8/19/25 with a terminal diagnosis of malignant neoplasm of upper lobe, left bronchus or lung [lung cancer]. Review of the Plan of Care for the certification period 8/19/25-10/17/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 2 times a week for 9 weeks; MSW [medical social worker] 1 time a month for 3 months; chaplain 1 time a month for 2 months. Review of the IDG [interdisciplinary group- team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed a meeting was conducted on 8/21/25. Review of the 8/25/25 IDG minutes revealed no visit projections for the next 15 days by the MSW. The patient revoked hospice on 9/3/25.3. Patient # 3 had a Start of Care date of 8/30/25 with a terminal diagnosis of interstitial pulmonary disease [a group of chronic lung conditions that cause inflammation and scarring of the lung tissue]. Review of the Plan of Care for the certification period 8/30/25-11/27/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 13 weeks; hospice aide 2 times a week for 13 weeks; MSW [medical social worker] 1 time a week for 1 week; chaplain 1 time a week for 1 week. A supplemental order for MSW visits was noted for 9/3/25 with a frequency of 1 time a month for 3 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed a meeting on 9/4/25. Review of the 9/4/25 IDT minutes revealed no visit projection for the next 15 days by the MSW. The patient passed away on 9/12/25.4. Patient # 4 had a Start of Care date of 12/19/24 with a terminal diagnosis of Alzheimer’s Disease [a progressive neurodegenerative disorder that affects memory, thinking, and behavior]. Review of the Plan of Care for the certification period 12/19/24-3/18/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks; hospice aide 2 times a week for 11 weeks; MSW [medial social worker] 1 time a month for 4 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed meetings were conducted on 12/26/24 and 1/9/25. Further review of the IDG minutes revealed no MSW visit projections for the next 15 days for either meeting. The patient passed away on 1/16/25.5. Patient # 6 had a Start of Care date of 8/22/25 with a terminal diagnosis of central nervous system lymphoma [cancer that affects the brain and spinal cord]. Review of the Plan of Care for the certification period 8/22/25-11/19/25 included orders for SN [skilled nursing] 1 time a week for 13 weeks; hospice aide 1 time a week for 13 weeks; MSW [medical social worker] 1 time a month for 3 months; chaplain 1 time a month for 4 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed IDG meetings were conducted on 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed no MSW visit projections for the next 15 days for the 9/19/25 or the 10/2/25 meetings. Review of the minutes for the 9/4/25 meeting revealed no entry by the MSW.6. Patient # 7 had a Start of Care date of 8/10/25 with a terminal diagnosis of idiopathic pulmonary fibrosis [a progressive disease characterized by a progressive and irreversible decline in lung function]. Review of the Plan of Care for the certification period 8/10/25-11/7/25 included orders for SN [skilled nursing [3 times a week for 1 week, 2 times a week for 12 weeks; MSW [medical social worker] 1 time a month for 3 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed meetings were conducted on 8/21/25, 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed no visit projections for the next 15 days by the MSW for the 8/21/25 or the 9/19/25 meetings. The IDG minutes revealed no MSW entry in the minutes for the 9/4/25 or the 10/2/25 meetings.7. Patient # 9 had a Start of Care date of 9/11/25 with a terminal diagnosis of heredity spastic paraplegia [large group of inherited neurologic disorders that share the primary symptom of difficulty walking]. Review of the Plan of Care for the certification period 9/11/25-11/9/25 included orders for SN [skilled nursing] 1 time a week for 9 weeks; hospice aide 2 times a week for 8 weeks, 1 time a week for 1 week; MSW [medical social worker] 1 time a month for 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed meetings were conducted on 9/19/25 and 10/2/25. Further review of the IDG minutes revealed no visit projections for the next visit days by the MSW for the 9/19/25 meeting. The 10/2/25 minutes revealed no entry by the MSW.8. Patient # 11 had a Start of Care date of 8/30/25 with a terminal diagnosis of Pompe Disease [disorder that affects muscles and other organs]. Review of the Plan of Care for the certification period 9/30/25-11/28/25 included orders for SN [skilled nursing] 1 time a week for 1 week, 2 times a week for 8 weeks; hospice aide 1 time a week for 1 week, 2 times a week for 8 weeks; MSW [medical social worker] 1 time a month for 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed an IDG meeting was conducted on 10/2/25. Further review of the IDG minutes for that date revealed no entry from the MSW.9. Patient # 12 had a Start of Care date of 9/15/25 with a terminal diagnosis of senile degeneration of the brain [a progressive decline in cognitive abilities that occurs with aging]. Review of the Plan of Care for the certification period 9/15/25-11/13/25 included orders for SN [skilled nursing] 2 times a week for 1 week, 1 time a week for 9 weeks; hospice aide 1 time a week for 9 weeks; MSW [medical social worker] 1 time a week for 1 week then 1 time a month for 3 months; chaplain 1 time a week for 1 week then 1 time a month for 3 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed IDG meetings were conducted on 9/19/25 and 10/2/25. Review of the IDG minutes for those dates revealed no visit projections for the next 15 days by the MSW.10. Patient # 15 had a Start of Care date of 8/20/25 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body’s needs]. Review of the Plan of Care for the certification period 8/20/25-11/17/25 included orders for SN [skilled nursing] 3 times a week for 2 weeks, 2 times a week for 11 weeks; hospice aide 2 times a week for 11 weeks; MSW [medical social worker] 1 time a month for 4 months; chaplain 1 times a month for 4 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed IDG meetings were conducted on 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed the MSW failed to project visit frequencies for the next 15 days during the 9/4/25 and 10/2/25 meetings. The minutes for the 9/19/25 revealed no MSW entry for that meeting date.11. Patient # 16 had a Start of Care date of 8/14/25 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body’s needs]. Review of the Plan of Care for the certification period 8/14/25-10/12/25 included orders for SN [skilled nursing] 1 time a week for 8 weeks; hospice aide 1 time a week for 8 weeks; MSW [medical social worker] 1 time a month for 3 months; chaplain 1 time a month for 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed meetings were conducted on 8/21/25, 9/4/25, 9/19/25, and 10/2/25. Further review of the IDG minutes revealed no entry by the MSW for the IDG meetings on 8/21/25, 9/4/25, or 10/2/25. The minutes for the meeting conducted on 9/19/25 revealed no visit projections for the next 15 days by the MSW.12. Patient # 18 had a Start of Care date of 11/29/24 with a terminal diagnosis of chronic kidney disease, stage 4 [severe kidney damage, where the kidneys function at 15-29% of their normal capacity]. Review of the Plan of Care for the certification period 9/25/25-11/23/25 included orders for SN [skilled nursing] 1 time a week for 8 weeks; MSW [medical social worker] [effective 10/1/25] 1 time a month for 2 months; chaplain [effective 10/1/25] 1 time a month of 2 months. Review of the IDG [interdisciplinary group-team of healthcare professionals who collaboratively create and manage a patient’s plan of care for holistic support] minutes revealed an IDG meeting was conducted 10/2/25. Review of the IDG minutes revealed no narrative note related to plan for next 15 days for the MSW.During an interview with the agency administrator and employee # 27 on 10/16/25 at approximately 10:15 am, it was confirmed that the MSW failed to update the the Plan of Care with projected visit frequencies.”

“Based on agency policy, clinical record review, and staff interviews, the agency failed to provide wound care in accordance with the plan of care for 3 of 7 patients with a wound [#1, 15, and 10]; failed to follow the plan of care related to visit frequency of 1 of 17 [#4] patients receiving aide services. The findings included: 4. Patient #10 had a Start of Care (SOC) date of 8/23/2025 and a terminal diagnosis of other symptoms and signs of cerebral infarction (cognitive impairment related to having a disruption of blood supply to a part of the brain causing tissue death). The Plan of Care (POC) for the certification period of 8/23/2025-11/20/2025 included orders for Skilled nursing (SN) 2 times a week for 13 weeks and “Skilled nurse to provide wound care twice a week. Remove old dressing, cleanse with soap and water or wound cleanser, pat dry, cover wound bed with xeroform and secure with bordered foam dressing.” Review of the clinical record revealed that on 8/26/25, RN (registered nurse) #14 documented wound dressing change as “cleansed with wound wash, pat dry, Vaseline impregnated gauze applied over wound bed, skin prep applied to peri-wound skin, covered with adhesive foam dressing.” Further review of the clinical record revealed that on 8/28, RN #14 documented wound dressing change as “cleansed with hygiene wipes, zinc paste applied, covered with adhesive foam dressing.” E-mail correspondence with the director on 10/16/2025 at 11:47 am confirmed that wound care orders had not been followed on the 8/26/25 and 8/28/25 SN visits. The policy, Plan of Care [3/25], was provided by the agency administrator on 10/15/25 at approximately 4:50 pm. The policy stated, “...the patient’s plan of care reflect [sic] the patient’s current health status, care needs...”The policy, Patient Visits-Scheduling [9/25], was provided by the agency administrator on 10/15/25 at 4:50 pm. The policy stated, “______ [agency name] shall insure all patient visits are scheduled and provided in accordance with the individualized plan of care, physician orders...Missed visits must be documented with the reason, and the physician notified...”1. Patient # 1 had a Start of Care date of 11/6/24 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body’s needs]. Review of the Plan of Care for the certification period 11/6/24-2/3/25 included orders for SN [skilled nursing] 2 times a week for 3 weeks, 1 time a week for 9 weeks, 3 PRN [as needed] for symptom management. Review of the clinical record revealed the following documentation by RN # 5 on 11/8/25, “PRN visit made tonight following a call from daughter...2 new skin tears to left arm...Wound care performed...” Further review of the clinical record revealed no orders for wound care. During an interview with RN # 3 on 10/17/25 at approximately 11 am, RN # 3 stated, “Sometimes the nurses will pull orders from the standing orders without writing them. I believe the correct method would be to write any specific order pulled from the standing orders.”2. Patient # 15 had a Start of Care date of 8/20/25 with a terminal diagnosis of severe protein-calorie malnutrition [condition where a person does not consume enough protein and calories to meet their body’s needs]. Review of the Plan of Care for the certification period 8/20/25-11/17/25 included orders for SN [skilled nursing] 3 times a week for 2 weeks, 2 times a week for 11 weeks and “Pressure Ulcer Stage 4 [a severe, deep open wound that extends through the skin and fat into the underlying muscle, tendon, ligament, or bone] sacrum [a triangular bone in the lower; situated between the two hipbones of the pelvis]: Cleanse with soap and water, apply Baza cream thick over area, leave open due to risk for soiling and infection. SN to assess at each visit”. Review of the clinical record revealed LPN # 10 conducted a visit on 8/27/25 and documented the following information,” ...Location: Sacral Pressure...Treatment: Cleanse with wound cleanser and gauze, dress with zero form [sic], covered with bordered gauze...” During an interview with the agency administrator on 10/16/25 at approximately 10 am, the director confirmed the area to the sacrum should not have had a dressing applied. 3A. Patient # 4 had a Start of Care date of 12/19/24 with a terminal diagnosis of Alzheimer’s Disease [a progressive neurodegenerative disorder that affects memory, thinking, and behavior]. Review of the Plan of Care [POC] for the certification period 12/19/24-3/18/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks; hospice aide 2 times a week for 11 weeks. Review of the clinical record revealed the patient received 3 hospice aide visits the week of 12/29/24. During an interview with employee # 27 on 11/16/25 at approximately 10 am, it was confirmed the patient received 3 hospice aide visits instead of 2 as ordered on the POC.3B. Patient # 4 had a Start of Care date of 12/19/24 with a terminal diagnosis of Alzheimer’s Disease [a progressive neurodegenerative disorder that affects memory, thinking, and behavior]. Review of the Plan of Care [POC] for the certification period 12/19/24-3/18/25 included orders for SN [skilled nursing] 2 times a week for 13 weeks; hospice aide 2 times a week for 11 weeks. Review of the clinical record revealed the hospice aide documented a missed visit on 12/26/24. There was no evidence the physician was notified of the missed visit. During an interview with the agency administrator on 10/16/25 at approximately 10 am, the administrator confirmed the patient did not receive aide services in accordance with the POC.”

“Based on agency policy, clinical record review, and e-mail correspondence the Hospice Aide care plan failed to include correct advanced directives for 1 out of 17 patients with hospice aide services (#8). The findings included: The policy, Hospice Aide Services, Assignments and Supervision HC. 19 (Revised 01/2025), was provided by the agency director on 10/16/25 at 12:10 pm. The policy stated, “Hospice Aide services are provided under the supervision of a registered nurse (RN)…The RN provides written or electronic patient care instructions before the hospice aide begins providing services…A hospice aide care plan is developed and updated by the RN based on the patient’s evolving needs.”Patient #8 had a Start of Care (SOC) date of 9/19/2025 and a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease (High blood pressure leading to kidney disease). The Plan of Care (POC) for the certification period of 9/19/2025 - 12/17/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 13 weeks; hospice aide 2 times a week for 13 weeks; Medical Social worker (MSW) 1 time a month for 4 months; Chaplain 1 time a month for 4 months. Review of the clinical record revealed a signed DNR (do not resuscitate-a medical order instructing healthcare providers not to perform life-saving measures if a person’s heart or breathing stops) dated 9/19/2025. Review of the Hospice Aide care plan dated 9/19/2025 indicated that the patient did not have a DNR in place. E-mail correspondence with the director on 10/16/2025 at 11:47 am confirmed the hospice aide care plan failed to include the patient’s DNR status.”

“Based on agency policy, clinical record review and staff interviews the agency failed to use volunteers in accordance with the Medicare Conditions of Participation. The policy, Volunteer Services [9/25], was provided by the agency administrator on 10/16/25 at approximately 11 am. The policy stated, “..._______ [name of agency] ensures the use of trained, supervised, and qualified volunteers to support patients, caregivers, and administrative operations...” During an interview with the agency director on 10/15/25 at approximately 3 pm, the director stated, “We haven’t had any volunteers since the end of 2023. We were able to retain volunteers before the pandemic but since then we haven’t been able to recruit any volunteers. We have a brochure that is in the admission packet. People just don’t want to go into patient’s home anymore.””

“Based on agency policy, clinical record review, and e-mail correspondence, the clinical record failed to include wound measurements for 1 out of 7 patients with a wound (#8). Findings include: The policy, Wound Care (revised 12/2024) was provided by the agency director on 10/14/2025 at 11:00 am. The policy stated, “…after the initial visit, skin integrity will be assessed at every subsequent visit…any open area will have the sites measured and documented weekly.”Patient #8 had a Start of Care (SOC) date of 9/19/2025 and a terminal diagnosis of Hypertensive Heart and Chronic Kidney Disease (High blood pressure leading to kidney disease). The Plan of Care (POC) for the certification period of 9/19/2025 - 12/17/2025 included orders for Skilled nursing (SN) 1 time a week for 1 week, 2 times a week for 13 weeks and “LLE (left lower extremity) wound…Cleanse wound with wound cleanser. Pat dry. Apply xeroform to wound bed. Cover with non-adherent gauze. Secure with rolled gauze and tape. Dressing to be changed twice a week”. Review of the clinical record revealed no wound measurements for the left lower leg wound on 9/25/2025.E-mail correspondence with the director on 10/16/2025 at 11:47 am confirmed the clinical record failed to include wound measurements on 9/25/25.”