Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 017009 (X3) Date Survey Completed 04/26/2018
Name of Provider or Supplier Eh Health Home Health Of Birmingham, Llc Street Address, City, State 1 Chase Corporate Drive, Suite 210 A, Hoover, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
G0000 An abbreviated onsite survey was conducted on 4/24/18 to 4/26/18 at Alacare Home Health and Hospice, Brimingham, to investigate complaint # AL 00035618. The complaint was substantiated and there following deficiencies were cited based on the survey.
G0570 Care planning, coordination, quality of care
CFR(s): 484.60

Condition of participation: Care planning, coordination of services, and quality of care. Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient's medical, nursing, rehabilitative, and social needs in his or her place of residence. Each patient must receive an individualized written plan of care, including any revisions or additions. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s), and the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care. The individualized plan of care must also specify the patient and caregiver education and training. Services must be furnished in accordance with accepted standards of practice.


This CONDITION is not met as evidenced by:
This condition level deficiency was cited based on review of medical records, agency policies and procedures, and interviews with staff, it was determined the agency failed to ensure:



1. Failed to follow wound care orders written by the physician.



2. Failed to notify and inform the physician of changes in patient's condition and care.



3. Failed to educate/ instruct and observe the patient and/ or family/ caregiver regarding the care of patient related to wound care, Percutaneous Endoscopic Gastrostomy (PEG) and Peripherally Inserted Central Cathe ter (PICC).



4. Perform onsite supervisory visit to patient's home evey 14 days regarding home health aide services and care.



Findings include:



Refer to G 578, G 590, G 610 and G808.
G0578 Conformance with physician orders
CFR(s): 484.60(b)

Standard: Conformance with physician orders.


This STANDARD is not met as evidenced by:
Based on observation, agency's policy and procedure, medical record (MR) reviews and staff interviews, it was determined the staff failed to follow physician's order for:



1. Wound care on 5 of 5 patients with wounds including MR # 1, # 2, # 3, # 4 and # 4



2. Enteral Feedings on 1 of 1 patient with enteral feedings including MR # 4 orders for physician ordered visits including MR # 1, # 3, # 4, and # 5.



3. Discipline's visit frequencies on 4 of 5 physician's ordered visits including MR # 1, # 3, # 4 and # 5.



This deficient practice has the potential to negatively affect all patients treated by the agency.



Findings include:



Policy: Monitoring Patient's Response/ Reporting to Physician

Policy No. HH 2-015

Revised: 11/2017



Purpose



To provide guidelines for monitoring the patient's response to care, and for reporting to the patient's physician.



Procedure



F. When there is a problem implementing the plan of care. This includes any service, frequency, and treatment.





1. MR # 1 was admitted to home health on 9/9/17 with the diagnoses including Abnormal Microbiologic Findings in Specimen from Respiratory Organ/ Thorax, Methicillin Resistant Staphylococcus Infection Causing Disease Elsewhere Classified and Pressure Ulcer Sacral Region, Stage IV.



Review of the Home Health Certification (HHC) and Plan of Care (POC) dated 9/9/17 to 11/7/17 revealed the following wound care orders: Stage III Mid Sacral, cleanse with dermal wound cleanser (DWC) or Saline, pat dry with gauze, may apply protective skin barrier wipe, apply Santyl to wound bed and lightly pack wound bed and undermined areas with Dakins moistened gauze, cover with abdominal pad (ABD), secure with paper tape. Provide Wound care at a frequency of: Skilled Nurse (SN) 1x (time) x 1 wk (week), 4 x wk x 1wk, 2x wk x 3 wks.



Review of the SN visit notes 4/24/18 revealed the SN missed one visit week of 9/10/17. Further review of the MR revealed a communication note dated 9/28/17 of a missed SN visit without the actual date the missed visit happened.



An interview conducted on 4/26/18 at 8:30 AM with Employee Identifier (EI) # 1 Branch Manager (BM) who confirmed the above mentioned findings.



2. MR # 2 was admitted to home health on 9/30/17 with the diagnoses including Sepsis, Unspecified Organism, Pressure Ulcer on Left Heel, Stage II, Pressure Ulcer on Right Heel, Stage II and Pressure Ulcer on Other Site, Stage 2.



Review of the HHC and POC dated 9/30/17 to 11/28/17 revealed the following wound care orders: #1 Left Heel, cleanse with DWC, pat dry with gauze, applied skin protective barrier wipe, apply Aquacel AG (silver impregnated dressing), cover with ABD pad, apply Kerlix and secure with tape. # 2 Pressure Ulcer (PU) Left Proximal Dorsum, cleanse with DWC, part dry with gauze, apply skin protective barrier wipe, apply Mepilex AQ, cover with Kerlix, secure with tape. # 3 Stage II, PU, Right Heel, cleanse with DWC, pat dry with gauze, apply protective skin barrier wipe, apply Mepilex AQ, cover with Kerlix, secure with tape.

Wound care to be provided at a frequency of: SN 3 x week.



Review of the SN SOC (Start of Care) visit note on 4/24/18 dated 9/30/17 4/24/18 revealed the following documentation: Wound labeled # 6 Left Proximal Dorsum and # 9 Stage III PU Left heel was cleansed with saline or DWC, pat dry with gauze, apply protective skin barrier wipe, applied Medihoney, and covered with Petroleum or Xeroform gauze, covered with Mepilex border, secured with rolled gauze and Coban; # 3 was Mid- Sacral Stage II PU and was "cleansed with DWC, pat dry with gauze, applied protective skin barrier wipe, applied Xeroform and bordered with Mepilex", # 8 Right Heel, Unstageable, there was no wound care provided, SN documented "observed and assessed for signs and symptoms of infection, Left open to air.

Review of the HHC and POC revealed there was no wound care ordered for the wound # 8 in the Mid Sacral area.



Further review of the SN SOC note 9/30/17 on 4/24/18 revealed the SN provided wrong physician orders to # 6 Left Proximal Dorsum and # 9 Left Heel. There was no order to apply Medihoney and cover wounds with petroleum or xeroform gauze with Mepilex border and secure with rolled gauze and Coban.



Further review of SN SOC note 9/30/17 on 4/24/18 revealed the SN provided wound care to # 3 Mid Sacral area # 8 Right Heel. There was no documentation of a Physican order (MD) found for # 3 Mid Sacral area # 8 Right Heel.



Review of the SN visit notes 4/24/18 revealed the SN documented on 10/6/17 the following " SN visit moved tomorrow due to awaiting for a new wound care supplies to be delivered". There was no documented visit made until 4 days later on 10/10/17 when wound care was provided.



An interview was conducted on 4/26/18 at 9:30 AM with EI # 1 who confirmed the staff failed to perform wound care as scheduled.



3, MR # 3 was admitted to home health on 11/6/17 with the diagnoses including Pressure Ulcer Of sacral Region, Stage IV and Myelodysplastic Syndrome, Unspecified.



Review of the HHC and POC dated 11/6/17 to 1/4/18 Revealed the following wound care orders: Stage IV Pressure Injury of Coccyx, cleanse with Saline or wound cleanser, pat dry with gauze, apply Santyl to wound bed, apply saline moistened gauze, cover with dry gauze followed with Mepilex foam dressing. May apply protective skin barrier wipe to periwound skin at a frequency of daily and measure at a minimum of weekly.



Review of the SN visit note 11/14/17 on 4/24/18 revealed no documentation wound on Sacral area and (R) Proximal Arm was measured according to the physician's POC.



Review of the Resumption of Care (ROC) 11/30/17 revealed the following wound care orders: cleanse wound Stage IV Pressure Injury to Coccyx with saline or wound cleanser, pat dry with gauze, apply Santyl (if not available substitute Hydrogel until Santyl is available) to wound bed, apply Saline moistened gauze, cover with dry gauze followed by Mepilex Foam dressing. May apply skin protective barrier to periwound skin. Wound care daily and agency to measure weekly.



Review of the SN visit notes dated 12/12/17 and 12/19/17 on 4/24/18 revealed no documentation wound on the Sacral Area and (R) Proximal Arm was measured according to the physician's ROC.



Review of the HHC and POC dated 11/6/17 to 1/4/17 revealed the Home Health Aide (HHA) to 1x for 1 wk, 2x for 3 wks and 1x for 4 wks.



Review of the MR visit notes 4/25/18 revealed there was 1 missed visit week of SOC (11/6/17). There was no documentation the physician was notified.



An interview was conducted on 4/24/18 at 8:45 AM with EI # 1 who confirmed the aforementioned findings.



4. MR # 4 was admitted to home health on 12/4/17 with the diagnoses including Pressure Ulcer of Right Buttock, Stage III and Hypertensive Chronic Kidney Disease, Stage I - IV.



Review of the HHC and POC dated 12/4/17 to 2/1/18 revealed the following wound orders: SN to apply Negative Pressure Wound Therapy (NPWT) to Right Upper Buttock and a frequency of 3 times a week. Cleanse/ Irrigate (R) Buttock with dermal wound cleanser/ saline, apply skin protective barrier to peri-wound skin. Cut the black Granufoam to fit the size and shape of the wound, place the foam into the wound cavity, picture frame the wound edges with transparent dressing, cover the sponge with transparent dressing. choose location on the dressing to apply trac pad, cut a hole thru the transparent dressing exposing the foam, apply the trac pad to the cut home and seal onto the dressing, connect trac pad tube to the canister and set the therapy setting to 125 millimeter of mercury (mm/Hg).



Review of the SN visit note 12/12/17 on 4/25/18 revealed documentation of the presence of tunneling on the coccyx measuring 2.5 cm. There was no documentation the physician was notified.



Review of the HHC and POC dated 12/4/17 to 2/1/18 revealed the disciplines visit frequencies: SN 4x for 1 wk, 3x for 7 wks and 1x for 1 wk.; Home Health Aide (HHA) effective 12/10/17 at 2x for 3 wks and 1x for 3 wks; Physical Therapy (PT) 2x for 3 wks, 1x for 1 wk, 2x for 4 wks and 1x for 1 wk.; Occupational Therapy (OT) 2x for 4 wks.



Review of the SN visit notes 4/25/18 revealed 1 missed visit week of 12/31/17. There was no documentation the physician was notified.



Review of the HHA visit notes 4/25/18 revealed 1 missed visit week of 12/17/17 and 2 missed visits week of 12/24/17. There was no documentation the physician was notified.



Review of the PT visit notes 4/25/18 revealed 1 missed visit week of 12/4/17 and 1 missed visit week of 12/17/17. There was no documentation the physician was notified.



Review of the OT visit notes 4/25/18 revealed 1 missed visit week of 12/17/17 Further review of the OT notes revealed no visits (2) were made week of 12/24/17.



In an interview conducted on 4/26/18 at 8:30 AM with EI # 1 who confirmed the staff failed to follow agency's policy and procedures.



5. MR # 5 was admitted to home health on 11/17/17 with the diagnoses including Pressure Ulcer of Left Hip, Stage III and Pressure Ulcer of Sacral region, Stage II.



Review of the HHC and POC dated 11/17/17 to 2/25/18 revealed the SN visit frequencies was 3 x for 4 wks, 2 x for 3 wks and 1 x for 2 wks.



Review of the MR (medical record) visit notes 4/25/18 revealed there were 2 missed visits the week of SOC (11/17/17) and 1 missed SN visit week of 11/24/17. There was no documentation the physician was notified.



An interview was conducted on 4/26/18 at 9:15 AM with EI # 1 who confirmed the above mentioned findings.
G0590 Promptly alert relevant physician of changes
CFR(s): 484.60(c)(1)

The HHA must promptly alert the relevant physician(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 review of the agency's policies and procedures, medical record review (MR) and interview, it was determined the agency failed to:



1. Notify the physician when a patients wound deteriorated in 4 of 5 records reviewed with wounds that deteriorated including MR # 1, # 2, # 4 and # 5.



2. Notify the physician the patient had not received the ordered feedings 1 of 1 record reviewed with tube feeding including MR # 4.



3. Inform the physician of problems related to the patient's Peripherally Inserted Central Catheter (PICC) care on 1 of 1 patient record reviewed including MR # 2.



This deficient practice had the potential to negatively affect all patient served by this home health agency.



Findings include:



Policy: Monitoring Patient's Response/ Reporting to Physician

Policy No: HH 2-015

Revised: 11/2017



Policy



Clinicians will establish and maintain ongoing communication with the physician to ensure safe and appropriate care for the patient.



Procedure



3. Licensed Clinicians will contact the Physician (MD) from bedside and note call on the vital sign communication tool when any of the following occur regarding, but not limited to the following:

A. Significant changes in the patient's condition.



E. Changes that have occurred regarding diagnosis, prognosis, or treatment (including procedures, medications, precautions and limitations.



4. All conference attempts to communicate with physician will be documented in the clinical record.



5. When unable to contact the patient's physician for medical consultation warranted by the change in the patient;s condition, the following procedures will be followed:

A. The nurse or therapist will immediately notify the Clinical Supervisor or designee regarding the need for medical consultation and problems encountered.

B. It remains the responsibility of the clinician originating MD contact to ensure appropriate follow-up was made.

C. Best clinical judgement should be utilized to ensure patient care needs are met timely.



1. MR # 1 was admitted to home health on 9/9/17 with the diagnoses of Stage IV Pressure Ulcer Sacral Region and Micro Findings of Specimen from the Respiratory System



Review of the Skilled Nurse (SN) SOC visit note 4/25/18 revealed on documentation of 1 area of undermining on # 1, Mid Sacral PU, Stage IV of 3 cm (centimeters) at 10 o'clock.



Further review of the MR revealed the presence of 2 undermining areas note on visit 9/18/17;

# 1- Stage IV PU Mid Sacral region with 1 cm (centimeter) at 7-8 o'clock and 0.5 cm at 4-6 o'clock. There was no documentation the physician was notified.



An interview was conducted on 4/26/18 at 9:00 AM with EI (Employee Identifier) # 1, Branch Manager (BM) who confirmed the above mentioned findings.



2. MR # 2 was admitted to home health on 9/30/17 with the diagnoses including Sepsis, Unspecified Organism, Pressure Ulcer on Left Heel, Stage II, Pressure Ulcer on Right Heel, Stage II and Pressure Ulcer on Other Site, Stage 2.



Review of the SN visit note 11/28/17 on 4/23/18 revealed documentation the wound on the Right Heel increased in size from 11/20/17 at 1.3 cm.(centimeter) L (length) c 2.5 cm W (width) x 0.1 cm D (depth) to 3.5 cm L x 4 cm W x 0 cm D. There was no documentation the physician was notified of the increased size of the Right Heel wound.



An interview was conducted on 4/26/18 at 9:30 AM with EI # 1 who confirmed the above mentioned findings.



3. MR # 4 was admitted to home health on 12/4/17 with the diagnoses including Pressure Ulcer of Right Buttock, Stage III and Hypertensive Chronic Kidney Disease, Stage I - IV.



Review of the HHC and POC dated 12/4/17 to 2/1/18 revealed the following wound orders: SN to apply Negative Pressure Wound Therapy (NPWT) to Right Upper Buttock and a frequency of 3 times a week. Cleanse/ Irrigate (R) Buttock with dermal wound cleanser/ saline, apply skin protective barrier to peri-wound skin. Cut the black Granufoam to fit the size and shape of the wound, place the foam into the wound cavity, picture frame the wound edges with transparent dressing, cover the sponge with transparent dressing. choose location on the dressing to apply trac pad, cut a hole thru the transparent dressing exposing the foam, apply the trac pad to the cut home and seal onto the dressing, connect trac pad tube to the canister and set the therapy setting to 125 millimeter of mercury (mm/Hg).



Review of the SN visit note 12/12/17 on 4/25/18 revealed documentation of the presence of tunneling on the coccyx measuring 2.5 cm. There was no documentation the physician was notified.



Review of the HHC & POC dated 12/4/17 to 2/1/18 the following PEG (Percutaneous Endoscopic Gastrostomy) feedings: administer 240 cc (cubic centimeters) of Jevity 1.5 bolus TID (three times a day) per PEG. Flush with 60 cc of water prior to and following feedings. ..



Review of the SN visit notes 12/13/17, 12/15/17, 12/18/17 and 12/20/ 17 on 4/25/18 revealed documentation the patient "has not received tube feedings". On 12/13/17 SN documented the agency clinical manager was notified. There was no documentation the physician was notified.



In an interview conducted on 4/26/18 at 9:00 AM with EI # 1 who confirmed the staff failed to follow agency's policy and procedures.



4. MR # 5 was admitted to home health on 11/17/17 with the diagnoses including Pressure Ulcer Left Hip, Stage III and Pressure Ulcer of Sacral Region, Stage II.



Review of the HHC and POC's Goals/ Rehabilitation Potential/ Discharge Plan dated 11/17/17 to 1/15/18 revealed documentation the patient's pressure ulcers will heal within 9 weeks.



Review of the SN visit note 12/5/17 on 4/25/18 revealed an increased in width measurement of the patient Left Iliac Crest , Stage III PU had increased from 2.8 cm (centimeter on 11/27/17 to 7.8 cm on 12/5/17. There was no documentation the physician was notified.



In an interview conducted on 4/26/18 at 9:15 AM with EI # 1 who confirmed the above mentioned findings.
G0610 Patients receive education and training
CFR(s): 484.60(d)(5)

Ensure that each patient, and his or her caregiver(s) where applicable, receive ongoing education and training provided by the HHA, as appropriate, regarding the care and services identified in the plan of care. The HHA must provide training, as necessary, to ensure a timely discharge.


This ELEMENT is not met as evidenced by:
Based on review of medical records (MR), agency policy and procedures, and interview with agency staff, it was determined the agency failed to ensure:



a) Education was provided to the patient/caregiver for wound care.



b) The patient or caregiver performed a return demonstration to ensure competency.



c) Instruction was given to family or caregiver regarding PEG (Percutaneous Endoscopic Gastrostomy) care and feeding including checking for residual.



This affected 5 of 5 wound care records reviewed including MR # 1, # 2, # 3, # 4, and # 5 and had the potential to negative affect all patients served by the home health agency.



Findings include:



Policy: Patient and Caregiver Education

Policy Bo. HH 5-104



Purpose

To provide guidelines for identifying and providing educational resources required to achieve learning objectives for patients and family/ caregivers.



Procedure:



2. Educational methods will be based on the patient's and family/ caregiver's ability to comprehend information and individual learning styles and may include, but not limited to, any of the following methods of instruction:

A. Verbal demonstration

B. Written demonstration

Demonstration and return demonstration

...

******

Skin Care- Wound Cleansing

Section: 7.26



After Care:



2. Instruct patient/ caregiver in the care of the wound including:

a. Reporting any changes in pain, drainage. temperature or other signs and symptoms of infection.

b. Techniques to change or reinforce dressings.

c. Diet to promote healing.

d. Medications/ disease processes that may be impending healing.

e. Activities permitted.





1. MR # 1 was admitted to home health on 9/9/17 with the diagnoses including Abnormal Microbiologic Findings in Specimen from Respiratory Organ/ Thorax, Methicillin Resistant Staphylococcus Infection Causing Disease Elsewhere Classified and Pressure Ulcer Sacral Region, Stage IV.



Review of the HHC and POC (Home Health Certification and Plan of Care) dated 9/9/17 to 1/7/18 revealed the order to: When applicable, teach caregiver to perform wound care.



Review of the SN visits on 4/24/18 dated 9/30/17, 10/4/17, 10/6/17, 10/10/17 and 10/12/17, 11/11/17, 11/15/17, 11/20/17 and 12/1/17 revealed no documentation the caregiver was taught how to perform wound care.



In an interview with Employee Identifier (EI) # 1, Branch Manager (BM) conducted 4/26/18 at 8:30 AM, EI # 1 confirmed the staff failed to follow agency's policies and procedures.



2. MR # 2 was admitted to home health on 9/30/17 with the diagnoses including Sepsis, Unspecified Organism, Pressure Ulcer on Left Heel, Stage II, Pressure Ulcer on Right Heel, Stage II and Pressure Ulcer on Other Site, Stage 2.



Review of the HHC and POC dated 9/30/17 to 11/28/17 revealed documentation on wound care orders as follows: When applicable teach caregiver to perform wound care.



Review of the SN visit notes on 4/24/18 dated 10/5/17, 10/6/17, 10/10/17, 10/14/17 and 10/17/17 revealed no documentation the patient or caregiver was instructed on wound care and/ or observed for return demonstration.



In an interview conducted on 4/26/18 at 9:30 AM with EI # 1 who confirmed the aforementioned findings.



3. MR # 3 was admitted to home health on 11/6/17 with the diagnoses including Pressure Ulcer Of Sacral Region, Stage IV and Myelodysplastic Syndrome, Unspecified.



Review of the HHC and POC dated 111/6/17 to 1/4/18 revealed the order to: When applicable, teach caregiver to perform wound care.



Review of the SN visit notes on 4/24/18 dated 11/6/17, 11/7/17, 11/14/17 revealed no documentation the patient and/ or the caregiver was instructed on wound care or return demonstration observed.



An interview was conducted on 4/26/18 at 8:45 AM with EI # 1 who confirmed the above mentioned findings.



4. MR # 4 was admitted to home health on 12/4/17 with the diagnoses including Pressure Ulcer of Right Buttock, Stage III and Hypertensive Chronic Kidney Disease, Stage I - IV.



Review of the HHC dated 12/4/17 to 2/1/18 revealed the order to: When applicable, teach caregiver to perform wound care. SN to teach in administration of PEG to include care of equipment and preparation of feeding. Administer 240 cc of Jevity 1.5 bolus TID. Flush PEG with 60 cc of water prior to and following feedings. Check for residual prior to administration of enteral formula or medications. If residual is greater than (>) 60 ml (milliliters) return gastric aspirate to stomach via PEG tube then recheck in one hour, if aspirate remains > 60 ml, return aspirate to stomach via PEG tube and notify the physician.



Review of the SN visit notes 4/25/18 dated 12/6/17, 12/12/17, 12/13/17, 12/15/17, 12/18/17, 12/20/17, 12/22/17, 12/24/17, 12/27/17, 12/28/17, 1/1/18, 1/13/18, 1/8/18, 1/10/18, 1/15/18 and 1/17/18 revealed no documentation the patient and or caregiver was instructed on how to administer tube feeding including checking for residual.



5. MR # 5 was admitted to home health on 11/17/17 with the diagnoses including Pressure Ulcer Left Hip, Stage III and Pressure Ulcer of Sacral Region, Stage II.



Review of the SN visit notes 4/25/18 dated 11/17/17, 11/20/17, 11/22/17, 11/27/17, 11/29/17, 12/3/17, 12/5/17, 12/11/17, 12/14/17, 12/18/17, 12/120/17, 12/27/17, 12/29/17 and 1/5/18 revealed no documentation the patient and/ or the caregiver was instructed on wound care or observed perform return demonstration.



In an interview conducted on 4/26/18 at 9:15 AM with EI # 1 who confirmed the above mentioned findings.
G0808 Onsite supervisory visit every 14 days
CFR(s): 484.80(h)(1)(i)

If home health aide services are provided to a patient who is receiving skilled nursing, physical or occupational therapy, or speech-language pathology services, a registered nurse or other appropriate skilled professional who is familiar with the patient, the patient's plan of care, and the written patient care instructions described in ยง484.80(g), must make an onsite visit to the patient's home no less frequently than every 14 days. The home health aide does not have to be present during this visit.


This ELEMENT is not met as evidenced by:
Based on reviews of the medical record (MR) and interview with agency administrative staff, it was determined the RN (Registered Nurse) failed to perform supervisory aide service no less than 14 days.



This affected 1 to 3 patients with home health aide services including MR # 4 and had the potential to negatively affect all patients served by the home health agency.



Findings include:



1. MR # 4 was admitted to home health on 12/4/17 with the diagnoses including Pressure Ulcer of Right Buttock, Stage III and Hypertensive Chronic Kidney Disease, Stage I - IV.



Review of the HHC and POC dated 12/4/17 to 2/1/18 revealed the discipline visit frequencies: Home Health Aide (HHA) effective 12/10/17 at 2x for 3 wks and 1x for 3 wks;.



Review of the Skilled Nurse (SN) Visit note 4/25/18 revealed no documentation a SVA (Supervisory Visit, Aide ) was performed the week of 1/7/18.



An interview was conducted on 4/26/18 at 9:00 AM with Employee Identifier (EI) #1, Branch Manager (BM) who confirmed the aforementioned findings.